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Translating evidence-based medicine into practice in critical care: an innovation study

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Translating evidence-based medicine into practice in critical care: an innovation study

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TRANSLATING EVIDENCE-BASED MEDICINE INTO PRACTICE IN CRITICAL CARE:
AN INNOVATION STUDY

By

Joan Brown

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2020

Copyright 2020 Joan Brown

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TABLE OF CONTENTS

List of Tables .................................................................................................................................. v

List of Figures ................................................................................................................................ vi

Abstract ......................................................................................................................................... vii

Chapter One: Introduction .............................................................................................................. 1
Organizational Context and Mission .......................................................................................... 2
Organizational Performance Status/Need ................................................................................... 3
Related Literature ........................................................................................................................ 5
Importance of the Organizational Innovation ............................................................................. 7
Organizational Performance Goal ............................................................................................... 7
Description of Stakeholder Groups ............................................................................................. 8
Stakeholder Group for the Study ................................................................................................ 9
Purpose of the Project and Questions ....................................................................................... 10
Methodological Framework ...................................................................................................... 10
Definitions................................................................................................................................. 11
Organization of the Study ......................................................................................................... 12

Chapter Two: Review of the Literature ........................................................................................ 13
Evidence-based Practice in Medicine ....................................................................................... 13
Quality Improvement ............................................................................................................ 14
Global Context ...................................................................................................................... 15
Emergence of Bundled Care Delivery .................................................................................. 16
ABCDEF Bundle in Critical Care ............................................................................................. 18
Post-ICU Syndrome (PICS) .................................................................................................. 18
ABCDEF Bundle Evidence .................................................................................................. 19
ABCDEF Implementation Barriers....................................................................................... 20
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework . 25
Stakeholder Knowledge, Motivation, and Organizational Influences ...................................... 26
Knowledge and Skills ........................................................................................................... 26
Motivation ............................................................................................................................. 34
Organizational Influences ..................................................................................................... 38

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Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and the
Organizational Context ............................................................................................................. 44
Influences of Focus ............................................................................................................... 44
Influence Interplay ................................................................................................................ 46
Summary ................................................................................................................................... 49

Chapter Three: Methods ............................................................................................................... 51
Participating Stakeholders ........................................................................................................ 51
Survey Sampling Criteria and Rationale................................................................................... 52
Survey Sampling (Recruitment) Strategy and Rationale .......................................................... 52
Document Review Sampling Criteria and Rationale ................................................................. 53
Document Review Sampling (Access) Strategy and Rationale ................................................. 54
Data Collection and Instrumentation ........................................................................................ 56
Surveys .................................................................................................................................. 57
Documents and Artifacts....................................................................................................... 59
Data Analysis ............................................................................................................................ 59
Validity and Reliability ............................................................................................................. 60
Ethics......................................................................................................................................... 62
Limitations and Delimitations................................................................................................... 64

Chapter Four: Results and Findings .............................................................................................. 68
Participating Stakeholders ......................................................................................................... 69
Survey Participants ............................................................................................................... 69
Document Review ................................................................................................................. 71
Results and Findings .................................................................................................................. 71
Knowledge Results ............................................................................................................... 72
Motivation Results ................................................................................................................ 84
Organizational Results .......................................................................................................... 92
Summary of Findings ................................................................................................................. 97
Summary of Validated Influences ........................................................................................... 103

Chapter Five: Recommendations ................................................................................................ 105
Recommendations for Practice to Address KMO Influences ................................................. 105
Knowledge Recommendations ........................................................................................... 108
Motivation Recommendations ............................................................................................ 112

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Organization Recommendations ......................................................................................... 117
Integrated Implementation and Evaluation Plan ..................................................................... 122
Organizational Purpose, Need and Expectations ................................................................ 123
Level 4: Results and Leading Indicators ............................................................................. 123
Level 3: Behavior ................................................................................................................ 125
Level 2: Learning ................................................................................................................ 129
Level 1: Reaction ................................................................................................................ 134
Evaluation Tools ................................................................................................................. 135
Summary ............................................................................................................................. 136
Implications for Practice ......................................................................................................... 137
Future Research ...................................................................................................................... 139
Conclusions ............................................................................................................................. 140

References ................................................................................................................................... 142

Appendices .................................................................................................................................. 155
Appendix A: Implementation Timeline .................................................................................. 155
Appendix B: Survey Items ...................................................................................................... 156
Appendix C: Survey Demographics and Response Rates ...................................................... 159
Appendix E: Motivation Survey Results ................................................................................ 164
Appendix F: Organization Survey Results ............................................................................. 166
Appendix G: Document Review ............................................................................................. 171
Appendix H: Sample Compliance Report ............................................................................... 175
Appendix I: Evaluation Tool Immediately Following the Program Implementation ............. 177
Appendix J: Evaluation Tool Delayed for a Period After the Program Implementation ........ 178
Appendix K: Sample Infographic for Data Analysis and Reporting ...................................... 180

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LIST OF TABLES

Table 1 Organizational Mission, Global Goal, and Stakeholder Goals ......................................... 9
Table 2 Knowledge, Motivation, and Organization (KMO) Worksheet: Knowledge ................. 33
Table 3 Knowledge, Motivation, and Organization (KMO) Worksheet: Motivation .................. 38
Table 4 Knowledge, Motivation, and Organization (KMO) Worksheet: Organization ............... 43
Table 5 Summary Table of Assumed Influences on Performance ............................................... 50
Table 6 Metacognitive Knowledge Statistics ............................................................................... 77
Table 7 Validated Knowledge Influences ..................................................................................... 83
Table 8 Utility Value Statistics ..................................................................................................... 85
Table 9 Self-Efficacy Statistics ..................................................................................................... 89
Table 10 Validated Motivation Influences .................................................................................. 91
Table 11 Validated Organization Influences ................................................................................ 97
Table 12 Summary of Validated Influences ............................................................................... 103
Table 13 Summary of Knowledge Influences and Recommendations ...................................... 105
Table 14 Summary of Motivation Influences and Recommendations ........................................ 112
Table 15 Summary of Organization Influences and Recommendations .................................... 117
Table 16 Outcomes, Metrics, and Methods for External and Internal Outcomes ...................... 124
Table 17 Critical Behaviors, Metrics, Methods, and Timing for Evaluation ............................. 125
Table 18 Required Drivers to Support Critical Behaviors ......................................................... 127
Table 19 Evaluation of the Components of Learning for the Program ....................................... 134
Table 20 Components to Measure Reactions to the Program ..................................................... 135
Table 21 Detailed Survey Questions ........................................................................................... 156
Table 22 Survey Recipients by Role ........................................................................................... 159
Table 23 Survey Respondents by Role ....................................................................................... 159
Table 24 Survey Response Rate by Role .................................................................................... 159
Table 25 Survey Item Response Rates ........................................................................................ 160
Table 26 Factual Knowledge Survey Responses ........................................................................ 161
Table 27 Conceptual Knowledge Survey Responses.................................................................. 161
Table 28 Procedural Knowledge Survey Responses ................................................................. 162
Table 29 Metacognitive Knowledge Survey Responses ............................................................. 162
Table 30 Utility Value Motivation Survey Responses ............................................................... 164
Table 31 Self-Efficacy Motivation Survey Responses .............................................................. 165
Table 32 Organizational Trust Survey Responses ...................................................................... 166
Table 33 Organizational Training Survey Responses ................................................................. 167
Table 34 Organizational Leadership Support ............................................................................. 169

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LIST OF FIGURES

Figure 1 Conceptual Framework: Practice Change in Critical Care ............................................. 47
Figure 2 Survey Distribution and Response ................................................................................. 70
Figure 3 Factual Knowledge ......................................................................................................... 73
Figure 4 Conceptual Knowledge .................................................................................................. 74
Figure 5 Procedural Knowledge Confidence Intervals ................................................................. 75
Figure 6 Procedural Knowledge ................................................................................................... 76
Figure 7 Metacognitive Knowledge Confidence Intervals ........................................................... 78
Figure 8 Metacognitive Knowledge.............................................................................................. 79
Figure 9 ABCDEF Bundle Protocol Compliance ......................................................................... 81
Figure 10 Utility Value Motivation Confidence Intervals ............................................................ 84
Figure 11 Utility Value Motivation .............................................................................................. 86
Figure 12 Self-Efficacy Motivation Confidence Intervals ............................................................ 88
Figure 13 Organizational Trust ..................................................................................................... 93
Figure 14 Organizational Trust ..................................................................................................... 94
Figure 15 Organizational Training ................................................................................................ 95
Figure 16 Organizational Leadership Support .............................................................................. 95
Figure 17 Training Program ........................................................................................................ 133
Figure 18 Implementation Timeline ........................................................................................... 155
Figure 19 Organizational Training .............................................................................................. 168
Figure 20 A Element Compliance............................................................................................... 171
Figure 21 B Element Compliance ............................................................................................... 171
Figure 22 C Element Compliance ............................................................................................... 172
Figure 23 D Element Compliance............................................................................................... 172
Figure 24 E Element Compliance ............................................................................................... 173
Figure 25 F Element Compliance ............................................................................................... 173
Figure 26 ABCDEF Bundle Compliance ................................................................................... 174
Figure 27 ABCDEF Bundle Compliance by Unit ...................................................................... 174
Figure 28 Sample ABCDEF Bundle Compliance Monthly Report ............................................ 175
Figure 29 Sample ABCDEF Bundle Patient Outcomes Monthly Report ................................... 176
Figure 30 Infographic Sample .................................................................................................... 180

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Abstract
This study applied the Clark and Estes (2008) gap analysis framework to the implementation of a
novel evidence-based protocol in the intensive care unit (ICU) known as the ABCDEF bundle.
The purpose of this innovation study was to examine the extent of knowledge and skill,
motivation, and organizational resources needed to reach the consistent implementation of the
ABCDEF bundle on 95% or greater of ICU patients. The analysis began by generating a list of
possible needs and moved to systematically validate the assumed influences. The study used
quantitative approaches to study the Clinical Team responsible for care in the ICU during
protocol implementation. A staff engagement survey with an 83% response rate combined with a
document review of ABCDEF bundle compliance reports over an annual period, were used to
assess gaps in knowledge, motivation, and organization influences. Findings from the study
identified strengths needed to sustain performance and weaknesses that required reinforcement to
improve. A key area for improvement included the need to cultivate the cross-discipline
collaboration and teamwork required to coordinate ABCDEF bundle care. Evidence-based
recommendations and a multidimensional training approach were developed to address identified
challenges and included all members of the Clinical Team responsible for care in the ICU in four
of the eight ICUs at the Medical Center. The approach and recommendations from the study can
be modified and applied to any healthcare institution pursuing the translation of evidence-based
medicine into daily practice.

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Chapter One: Introduction
This research study addresses the problem of adopting evidence produced by research
into medical practice within critical care in the United States. This approach to healthcare
delivery, referred to as evidence-based medicine, urges clinicians to translate latest advances in
scientific knowledge into their daily clinical routine (Drolet & Lorenzi, 2011; Grol & Grimshaw,
2003; Lenfant, 2003; Woolf, 2008). Evidence-based medicine, also termed as translational
medicine or implementation science, remains a challenge across the healthcare industry due to
several cultural and operational barriers (Grol & Grimshaw, 2003; Proctor et al., 2015; Jordan et
al., 2016). The challenge to translational medicine has become apparent in the critical care
domain, where efforts to implement an evidence-based healthcare delivery approach known as a
quality bundle, has shown poor adoption world-wide (Boehm et al., 2016; Boltey et al., 2019;
Masica et al., 2015; Miller et al., 2015). A quality bundle is a series of care processes that when
performed together are proven to improve the outcomes of patients (IHI, n.d.). The quality
bundle, known as the ABCDEF bundle, was established by the Society of Critical Care Medicine
(SCCM) and evaluated by a 67 site intensive care unit (ICU) Liberation Collaborative to assess
the impact of the systematic bundle process on the quality of care for the critically ill (Barnes-
Daly et al., 2018; Ely, 2017; Pun et al., 2019). The ABCDEF bundle’s prime objective is to
optimize healing while liberating patients from machine support and preventing pain, agitation,
delirium, and avoiding Post-ICU Syndrome (PICS). PICS is a medical condition characterized by
mental, psychological, and/or physical debilitation known to reduce the quality of life of patients
after they are discharged (Boehm et al., 2016; Davidson et al., 2013; Ely, 2017; Myers et al.,
2016). Recent research shows the ABCDEF bundle of care significantly improves patient
outcomes, but it is not widely implemented as a standard practice in the everyday clinical

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workflow (Boehm et al., 2016; Masica et al., 2015; Miller et al., 2015; Pun et al, 2019). The lack
of adoption of the ABCDEF bundle as an evidence-based practice demonstrates that translational
medicine in critical care is an important challenge to address.
The evidence highlights that despite the billion-dollar investment in research to advance
medical practice worldwide, there is limited understanding of how to translate research results
into clinical routine sustainably (Edward et al., 2017; Proctor et al., 2015). This problem is
important to address because the ongoing delivery of evidence-based interventions has a positive
impact on patient’s health and has been shown to improve patient outcomes, increase efficiency,
and reduce cost within critical care and beyond (Ely, 2017; Jordan et al., 2016; Proctor et al.,
2015).
Organizational Context and Mission
The Medical Center (pseudonym) is a tertiary care, academic health center, that provides
complex, specialized surgical, medical, and oncology health care. The Medical Center exists to
provide exceptional medicine to the acutely ill, leveraging the most cutting-edge, and
personalized medicine to the community and beyond. Centrally located in the western part of the
United States, the organization is comprised of three acute care hospitals: a 401-bed private
hospital, a 60-bed comprehensive cancer center, and a 158-bed community hospital, serving a
diverse population.
Within the organization, there are eight diverse specialty intensive care units (ICU): two
medical and surgical cardiovascular units, two surgical units, one transplant unit, one neurology
unit, one pulmonary and medical unit, and one oncology unit. All ICUs are currently structured
as an “open” model, in which the primary service consults the expertise of either Pulmonary,
Surgical, or Anesthesia Critical Care Service (Pronovost et al., 2006). As an academic health

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center, the critical care team is led by a critical care intensivist and often equipped with second-
year residents and fellows, as well as advanced practice professionals including nurse
practitioners, pharmacists, nurses, respiratory therapists, and physical therapists that provide 24-
hour intensive care coverage for the hospital (Ward et al., 2013).
Organizational Performance Status/Need
ABCDEF bundle implementation has been a challenge at the Medical Center. Despite
the Medical Center’s participation in the ICU Liberation Collaborative, the organization’s
compliance results fall below the Institute of Healthcare Improvement’s (IHI) 95%
recommendation for care bundle delivery and the ICU Liberation Collaborative peer
benchmarks (Resar et al., 2012; Society of Critical Care Medicine, 2017).
The Surgical ICU within the Medical Center joined the ICU Liberation Collaborative
in August 2015 as one of 67 sites. The collaborative measured compliance by both individual
element and the elements as a whole bundle. Each element could be compliant on a scale of
zero to 100%, however complete bundle compliance was defined as achieving all six bundle
elements in a 24-hour period. The collaborative weighted each bundle element equally in the
calculation for total bundle compliance (Pun et al., 2019). The ABCDEF bundle elements are
broken down into the following processes of care: (a) A for the assessment of pain; (b) B for
Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT); (c) C for choice
of analgesia and sedation; (d) D for delirium; (e) E for early mobility and exercise; and (f) F for
family and patient engagement (Marra et al., 2017).
At the onset of the initiative, the Medical Center’s compliance to each bundle element
(A: 89%; B: 0%; C: 0%; D: 0%; E: 40%; F: 0%), and the bundle as a whole (ABCDEF: 0%),
was reported between zero to 60% (Society of Critical Care Medicine, 2017). By the end of

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the ICU Liberation Collaborative study in April 2017, compliance increased to reach the IHI
95% recommendation for some elements but not all (A: 100%; B: 100%; C: 73%; D: 89%;
E: 62%; F: 58%; ABCDEF: 22%). The organization failed to maintain consistent results over
time.
While compliance did improve over the study and exceeded the national average of
18%, the Medical Center’s compliance to the entire bundle at 22% is considered
underachieving per the IHI recommendation of 95%. This could be due to several factors that
other centers experienced in their ABCDEF bundle implementation. The ABCDEF bundle
requires care coordination and clear accountability for its execution. In their qualitative and
multidisciplinary study, Boehm et al. (2016) noted that the roles and responsibilities of the
bundle were ambiguous, leading to variation in the understanding of how to reach compliance to
each element. The study further emphasized that: (a) culture; (b) team dynamics; (c) time
constraints; (d) need for multiprofessional coordination, were impediments to increasing
compliance. Edward et al. (2017) supported cultural barriers as a key factor that undermined the
urgency for clinicians to adopt new practice. Other studies cite additional challenges such as the
number of process within a bundle, the complexity of multiprofessional coordination (Resar et
al., 2012), the requirement for reliable infrastructure, overall resistance to change (Boehm et al.,
2016; Jordan et al., 2016) and the need for substantial improvement in education (Pinto &
Biancofiore, 2016).
Evidence demonstrates that implementing the ABCDEF bundle in the ICU results in an
increase in positive patient outcomes. However, the challenges presented in multiple studies
demonstrate the complexities of incorporating the bundle into clinical workflow. The medical
community considers the consequences of not implementing the ABCDEF bundle severe,

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including higher rates of mortality, decreases in patient’s quality of life, and increased hospital
length of stay (Pun et al., 2019). These benefits provide the impetus for the Medical Center and
multiple organizations across the United States to allocate resources to the adoption of the
ABCDEF bundle in all ICU’s.
Related Literature
Billions of dollars are invested annually in ground-breaking research to advance medicine
globally (Proctor et al., 2015). Results from this research often substantiate the need for a change
in clinical practice to increase the quality of care and outcomes for patients seeking medical care.
Despite this evidence, there remains a gap in translating the research results into a standard
clinical practice (Drolet & Lorenzi, 2011; Grol & Grimshaw, 2003; Lenfant, 2003; Proctor et al.,
2015).
A study aimed at assessing the quality of healthcare delivered to adults in the U.S.
produced poor results (McGlynn et al., 2003). Among the 17,937 eligible adults in a sample
across 12 metropolitan areas in 2003, only 54.9% received the recommended processes involved
in their needed care. The authors of this study posed a call to action to address this deficit in
clinical practice. Since 2003, additional studies have underlined the importance of bridging the
gap between research and practice (Boehm et al., 2016; Coles et al., 2017; Ericksson & Mullern,
2017). These researchers have stated the inability to translate evidence into practice limits the
capability to advance healthcare and provide high quality care to patients. Improvement in the
quality of healthcare delivery necessitates strategic implementation of evidence-based guidelines,
as well as inter-professional collaboration and training in performance improvement.
Healthcare represents almost 15% of the United States gross national product (GNP), but
remains behind in its performance evaluation and ability to benchmark across service providers.

6

Variation in hospital production models, acuity of patient population served, care level of
providing hospital, measurement approach, and lack of common data definitions are a few of the
factors that have hindered the advancement of monitoring and evaluation across the medical
community (Ozcan, 2008). The inability to measure performance across institutions stunts
improvement efforts focused on increasing the quality of care provided by healthcare systems.
The lack of performance measurement has become problematic in the last decade, where
evidence is needed to understand what conditions new healthcare delivery approaches require to
ensure integration into daily practice (Proctor et al., 2015).
Evidence demonstrates there is an improvement in patient outcomes if new healthcare
delivery approaches, known as bundled care approaches, are performed in clinical care daily
(Proctor et al., 2015; Pronovost et al., 2006; Resar et al., 2012). The Institute of Healthcare
Improvement (IHI) supported the improvement of patient outcomes in their detailed analysis
of bundled approaches. As a result of their evidence, the IHI released guidelines for the
implementation of any type of quality focused bundled care that recommends a target goal of
greater than 95% compliance (Resar et al., 2012).
The release of a multicomponent quality approach, known as the ABCDEF bundle was
established as an ICU Liberation Collaborative approach by the Society of Critical Care
Medicine (SCCM) and evaluated by the 67 site collaborative in 2016. The collaborative
aimed to assess the broad impact of the bundle on the quality of care in the ICU, with
benchmark comparisons across the participating institutions (Barnes-Daly et al., 2018; Ely,
2017). Evidence shows that the ABCDEF bundle of care improves patient outcomes but has
not been adopted into daily clinical practice across the United States (Boehm et al., 2016;
Masica et al., 2015; Miller et al., 2015; Pun et al, 2019).

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Importance of the Organizational Innovation
Implementation of evidence-based practices is especially significant in the care of the
most at-risk patients in the hospital, those cared for in the ICU. The consequences of not
implementing the ABCDEF bundle as a best practice evidence-based protocol include higher
rates of mortality and lower quality of life for all patients admitted to an ICU (Barnes-Daly et al.,
2018; Ely, 2017, Gill et al., 2016, Pun et al., 2019). Failure to implement this approach places
patients at risk for PICS, characterized by significant mental, psychological, and/or physical
debilitation that remains after transferring out of the ICU. Overcoming cultural and operational
barriers are needed to enable an environment that promotes translating advances in medicine into
practice to provide high quality care and improved outcomes to patients worldwide.
Organizational Performance Goal
The Medical Center strives to provide exceptional medicine to the acutely ill, leveraging
the most cutting-edge and personalized medicine to the community and beyond (Medical Center,
n.d.). To extend this mission to improve care for the critically ill treated in the ICU, the Medical
Center created the Critical Care Center (pseudonym) in 2015. The Critical Care Center (CCC)
is an executive leadership team comprised of leaders of the medical center and the medical
school that integrates the disciplines of the critical care specialty into a shared governance
structure.
To achieve their vision of leading the medical community in delivering leading edge,
high quality, patient-centered, and innovative care, the CCC set an organizational goal to
consistently implement evidence-based best practice protocols on 95% or greater of the
patients in the ICU for every shift by December 2025, as deemed clinically appropriate for
patients. The CCC based this goal on evidence released in the last decade, demonstrating the

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use of evidence-based protocols and bundled care approaches improved patient outcomes
(Proctor et al., 2015; Pronovost et al., 2006). In their evaluation of bundled care approaches,
the Institute of Healthcare Improvement (IHI) offered guidelines for the implementation of
bundled care and recommend a goal of greater than 95% compliance (Resar et al., 2012).
Description of Stakeholder Groups
Key stakeholder groups that contribute to and benefit from the CCC’s achievement of
evidence-based best practice care include the Medical Center, the critical care clinical team, as
well as the patients and families who seek care from the institution. The Medical Center is
responsible for providing highly specialized, tertiary level care to the community it serves. The
organization has a responsibility to ensure care meets government regulations, intersects industry
benchmarks, and provides value. The Medical Center’s mission provides the direction and
impetus for the CCC to consistently deliver the best care possible. The critical care clinical team
is responsible for adopting new clinical practice and demonstrating its use within each ICU.
Reaching the 95% compliance goal is contingent on the daily practice of the multiprofessional
clinical team of physicians, nurses, physical therapists, respiratory therapists, and nurse
practitioners on each of the eight ICUs of the Medical Center. Additionally, patients and their
families play a role in reaching this compliance target (Davidson et al., 2017; Hetland et al.,
2017). It is necessary for the patients to abide by the care plan set forth by the clinical team when
they are implementing new or existing protocols. Resisting the instruction of the clinical team
results in reduced protocol compliance. Achieving target compliance performance is impacted by
the practice and engagement of all key stakeholder groups.

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Stakeholder Group for the Study
Although a comprehensive analysis would include all stakeholder groups, this study
examined the clinical team responsible for patient care in the ICU. A focus on the entire clinical
team is necessary as partial and total bundle protocol compliance is defined by the action of each
team member in coordination with one another. Daily adherence to the protocol by the clinical
team was crucial to reaching 95% or greater compliance to evidence-based best practice for all
patients in the ICU by December 2025.
To reach this global goal, the critical care clinical team needs to set an intermediate
goal to leverage the evidence-based critical care best practice called the ABCDEF bundle on
greater than or equal to 95% of patient cases by March 2021. The target of 95% aligns with the
CCC’s global goal and was measured by the given definition of ABCDEF bundle compliance in
a seminal article evaluating the benefits of the approach in a multisite study with over 15,000
adults across the United States (Pun et al., 2019). The use of the study’s definition will allow the
researcher to compare of results to national benchmarks.
The consequences of not implementing the ABCDEF bundle are extensive, including
higher rates of death and lower quality of life for all patients admitted to an ICU (Pun et al.,
2019). These consequences are in direct conflict with the CCC’s mission to provide high quality
patient care, leveraging the latest advances in medicine, and the Medical Center’s goal to reduce
length of stay to meet industry benchmarks set by healthcare regulatory bodies.
Table 1
Organizational Mission, Global Goal, and Stakeholder Goals

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Purpose of the Project and Questions
The purpose of this project is to study and measure the extent of knowledge and skill,
motivation, and organizational resources necessary to reach the consistent implementation of
evidence-based best practice protocols on 95% or greater of ICU patients by December 2025.
The analysis began by generating a list of possible needs and then moved to examining these
systematically to focus on actual or validated needs. While a complete needs analysis would
have focused on all stakeholders, for practical purposes the stakeholder of focus was the ICU
clinical team. The study aimed to answer the following research questions:
1. What is the ICU Clinical Team’s knowledge and motivation related to implementing the
ABCDEF bundle on greater than 95% of ICU patient cases within the Critical Care
Center?
2. What is the interaction between the Critical Care Center’s culture and context and the
ICU Clinical Team’s knowledge and motivation related to implementing the ABCDEF
bundle on greater than 95% of ICU patient cases within the Critical Care Center?
3. What are the recommended knowledge, motivation, and organizational solutions?
Methodological Framework
The research questions guiding this study are descriptive questions which can be
answered by either a descriptive qualitative or quantitative methodological approach. Because
Organizational Mission
Establish the Critical Care Center as a world-class leader in critical care delivery, education,
research, and outreach.
Organizational Performance Goal
By December 2025, the Critical Care Center will consistently implement evidence-based, best
practice protocols on 95% or greater of the patients in the ICU for every shift.
Stakeholder Goal
By March 2021, the critical care clinical team will use the ABCDEF Bundle on greater than or
equal to 95% of patient cases that have appropriate indication for this treatment.

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the purpose of this study, however, is to study and measure the extent of the knowledge and skill,
motivation, and organizational resources necessary to achieve the organizational goal, a
quantitative methodological approach was used to achieve this purpose. The quantitative
methodology will leverage descriptive statistics and an applied action research approach
(Creswell & Creswell, 2018; McEwan & McEwan, 2003; Stringer, 2014). This
methodological approach follows the convention of existing seminal articles found in the
literature (Barnes-Daly et al., 2018; Ely, 2017; Pun et al., 2019), allowing for benchmarking
and performance evaluation against other medical institutions (Ozcan, 2008). Data gathering
and analysis will take the form of the conceptual framework described by Clarke and Estes
(2008) gap analysis. The author’s conceptual framework presents a systematic identification
and analysis of the knowledge, motivation, and organizational influence on the gap between
set performance goals and actual performance sustained. The Researcher would leverage the
framework to devise approaches to increase organizational performance (Clarke & Estes,
2008).
Definitions
ABCDEF Bundle: A bundled care approach used in the ICU. The bundle elements are
broken down into: A for the assessment of pain; B for Spontaneous Awakening Trials (SAT) and
Spontaneous Breathing Trials (SBT); C for choice of analgesia and sedation; D for delirium; E
for early mobility and exercise; and F for family and patient engagement (Marra et al., 2017).
Bundled Care: A healthcare delivery model that combines procedures or protocols in a
systematic delivery process over a defined time period for a specific medical condition (IHI,
n.d.).

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Intensive Care Unit (ICU): “The intensive care unit is a specialized hospital unit
dedicated to the care of patients requiring life support and those at extremely high risk for organ
failure and death. ICUs care for the most severely ill hospitalized patients and, in doing so, are
one of the most resource-demanding and stressful areas of the hospital” (Ervin et al., 2018, p.
468).
Information Technology (IT): The underlying technology used to document and gather
data for a patient’s hospital stay.
Interprofessional care: “Interprofessional care is defined as a team of clinicians with
intersecting knowledge, contributing that knowledge and collaborating to achieve a common
goal for patient care” (Donovan et al., 2018, p. 980).
Tertiary care: “Highly specialized medical care usually over an extended period of time
that involves advanced and complex procedures and treatments performed by medical specialists
in state-of-the-art facilities” (Merriam-Webster, n.d.)
Organization of the Study
The study is reviewed within five distinct chapters. Chapter One provided a detailed
overview of the problem of practice. Chapter Two reviews related literature to the problem and
outlines the knowledge, motivation, and organizational influences investigated in the study.
Chapter Three outlines the methodological approach and design of the study. Chapter Four is an
analysis of the data gathered during the study. Chapter Five extends the discussion of results to
recommendations of actions needed to close the performance gap related to the problem of
practice.

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Chapter Two: Review of the Literature
This literature review will examine evidence-based practice in healthcare and the root
causes of gaps in the implementation of the ABCDEF bundle in critical care. The review begins
with studies that illustrate the challenges of implementation, continues with an examination of
the efficacy of the healthcare delivery system, and concludes with the quality improvement needs
and the state of translational medicine. The chapter continues with research supporting the
delivery of bundled care for quality improvement, a description of evidence-based medicine in
critical care known as the ABCDEF bundle, and the challenges documented in the field on
ABCDEF bundle implementation. The chapter ends with an analysis utilizing the Clark and
Estes (2008) Gap Analytic Conceptual Framework that includes the knowledge, motivation, and
organizational influences on the critical care clinical team’s ability to implement the ABCDEF
Bundle in daily practice.
Evidence-based Practice in Medicine
Closing the gap between research and practice in healthcare dates back to early 2000,
when the Institute of Medicine (IOM) stated the absence of the implementation science
methodology as a general problem of practice in medicine. The seminal IOM report cited patient
safety as a major public health problem that needed to be improved across the industry
(Donaldson et al., 2000). The report estimated that roughly 98,000 people die each year due to
medical errors, contributing to 2 - 4% of deaths in the U.S. These errors were estimated to
account for a total of $17 - 29 billion in healthcare costs. Both reduction of this cost and quality
improvement can be addressed by implementing advances in medicine into daily routine.
Changing medical practice using evidence produced in research that validate
improvement in healthcare delivery is known as evidenced-based practice, bench-to-bedside, or

14

the translational continuum of medicine (Drolet & Lorenzi, 2011; Grol & Grimshaw, 2003;
Lenfant, 2003; Woolf, 2008). The National Institute of Health (NIH) marked the importance of
translating research into practice by placing translation of scientific knowledge in clinical care as
a pivotal step in improvement on their strategic roadmap (Zerhouni, 2003). The NIH continued
to demonstrate the importance of bridging science and clinical medicine by founding Clinical
and Translational Science Awards (CTSA) grants beginning in 2005 to the present day, with a
budget of 500 million annually (Woolf, 2008; Zerhouni, 2005). In addition to this investment,
the Agency for Healthcare Research and Quality (AHRQ) allocates $300 million annually to
fund research that can be used to translate research into healthcare delivery across the United
States (Woolf, 2008). Addressing rising healthcare costs by translating evidence-based practice
in medicine is considered essential to improving the quality of healthcare delivery by the medical
community and the federal agencies that exist to be a catalyst for healthcare improvement like
the NIH, AHRQ and the IOM.
Quality Improvement
In March of 2001, the IOM produced an additional policy brief to influence the medical
community to acknowledge the distance between the healthcare delivery of today and what it
should be (Briere, 2001). It urged healthcare practitioners to recognize that the United States
healthcare system remains deficient in its aptitude to include the best available scientific
evidence in every day clinical decision making. The policy stated “crossing the quality chasm”
needed to be addressed with a sense of urgency in all aspects of healthcare delivery. Five years
following the IOM reports, there was an uptake in efforts to make healthcare safer by changing
the way the systems function. Within these improvement attempts, errors were viewed primarily
as a result of the healthcare system’s design rather than a result of individual providers’ errors.

15

This insight has led to the conclusion that healthcare delivery systems need to transform to
support safe clinical practice (Leape & Berwick, 2005).
Two years following the IOM reports, the IOM’s conclusions were supported by a
systematic review of 235 studies evaluating implementation strategies in the United States and
the Netherlands. In this review of the proportion of patients receiving appropriate treatment
across all studies, Grol and Grimshaw (2003) found that “30-40% of patients do not receive care
according to present scientific evidence, and about 20–25% of care provided is not needed or is
potentially harmful” (p. 1225). They concluded that major difficulties were multifactorial and
hindered the ability to translate evidence of proven best practice protocols into clinical routine.
Over a decade later, the prevalence of this problem of practice presents itself as an
ongoing challenge in healthcare. Proctor et al. (2015) gathered a group of 94 experts during an
intensive workshop to provide recommendations on how to sustain evidence-based innovations
in healthcare. The group stated that the healthcare industry is inadequate in their attempt to
integrate quality health care into routine practice (Proctor et al., 2015). This is in spite of the
annual investment of tax revenue in the United States, as well as investment from countries
worldwide, on studies focused on creating, trialing, and applying evidence-based medicine.
Global Context
The challenges related to translating scientific evidence into daily practice is not unique
to the United States and has presented itself globally. A study of 65 nurses across the Eastern
Cape Province in South Africa (Jordan et al., 2016), and of nine hospitals in Australia (Edward et
al., 2017) both show compelling evidence that new practice would significantly improve
outcomes and increase efficiency. Both authors claimed that individual and system-wide barriers
could obstruct the application of evidence-based practice, along with an engrained clinical

16

culture that focuses on ritualistic practice and firmly held ideals. The concept of bundle care
emerged to mitigate the examples of system-wide barriers described by these studies. The IHI
developed the bundled healthcare delivery approach in 2001 to confront the barriers faced in the
global medical community (Resar et al., 2012).
Emergence of Bundled Care Delivery
Bundled care emerged as a strategy to standardized healthcare delivery and translate
research evidence that demonstrated improvement in patient outcomes. The bundle approach is
defined as applying clinical processes with a robust evidence base known to produce better
patient outcomes when applied jointly compared to individually (Resar et al., 2012). Three
bundle care approaches have exhibited improved patient outcomes that were developed and
studied within the last two decades. The central line infection, ventilator, and sepsis bundles
research evidence support the emergence of bundle care delivery and the need to explore the
implementation of healthcare bundles in other areas of patient care.
Central Line Associated Bloodstream Infection (CLABSI) Bundle. Hospital acquired
infections are a significant challenge in healthcare systems and ICUs globally (Ista et al., 2016;
Pronovost et al., 2006). Acquiring an infection in the hospital is associated with impaired
immunity and an increased risk in blood stream infections that can be fatal (Ista et al., 2016). An
evidence-based protocol was created by the IHI to prevent, manage, and reduce the incidence of
CLABSI. The use of the bundle by the medical community has resulted in statistically significant
reduction in this life-threatening ailment (Furuya et al., 2016; Ista et al., 2016; Pronovost et al.,
2006). In an 18-month study, the CLABSI bundle protocol demonstrated a sustained reduction of
up to 66% (Pronovost et al., 2006). Similar results were observed a decade later, where a study
comprised of 1000 adult ICUs reported that whole or partial bundle compliance was associated

17

with a reduction CLABSI rates across ICUs (Furuya et al., 2016). Despite a common protocol,
the variability in practice within each of the 1000 ICUs in this study was noted as an area for
improvement in CLABSI reduction nationally.
Ventilator Bundle. As in the case of CLABSI, a bundle approach was developed based
on evidence to combat Ventilator Associated Pneumonia (VAP). Whole or partial use of the
bundle demonstrated a statistically significant reduction in VAP (Crunden et al., 2005; Morris et
al., 2011; Zilberberg et al., 2009). VAP bundle utilization yielded additional benefits, including
reduced ventilator hours and ICU length of stay, both indicators of improved patient outcomes
(Crunden et al., 2005). The benefits of the VAP bundle are accompanied with challenges to its
adoption. Jansson, Syrjälä et al. (2018) cite variation in practice, lack of education and skills,
limited resources, and environmental factors as barriers to bundle adherence.
Sepsis Bundle. Similar to CLABSI and VAP, incidence of sepsis shock can have a
severe negative impact to patient outcomes (Levy et al., 2004). Evidence from decades of
research uncovered the link between applying bundle approaches to manage sepsis with a
decrease to mortality and morbidity rates (Levy et al., 2018; Levy et al., 2004; Nguyen et al.,
2007). The creation of the sepsis bundle protocol was the medical community’s effort to translate
research on effective therapies into bedside practice (Levy et al., 2004). The use of the sepsis
bundle protocol resulted in statistically significant reduction in mortality (Nguyen et al., 2007).
Achieving increased compliance to produce the statistically significant results took two years to
achieve more than 50% compliance, with an ongoing target of 95% from the onset of the
initiative.
Spiegel et al. (2018) warned against assuming that sepsis bundle care is superior to
individual care processes. The authors state that sufficient evidence is needed to support bundle

18

care delivery over alternate methods that may produce equal or better clinical quality and patient
outcomes. Since the formation and use of the CLABSI, VAP, and sepsis bundles, the use of
bundle care has emerged as a trend in the industry used to improve clinical care and translate
research into daily practice. The evidence demonstrating statistically significant improvement in
patient outcomes has supported expanding study focus to other areas of healthcare delivery.
ABCDEF Bundle in Critical Care
Translating research evidence into daily practice is challenging in healthcare across the
world and quality bundles like CLABSI, VAP, and sepsis. This is no exception in the domain of
critical care, where achieving the quality and patient care gains evident in multi-year global
studies of ABCDEF bundle implementation is not widely adopted as standard practice in ICUs
(Boehm et al., 2016; Donovan et al., 2018; Masica et al., 2015; Miller et al., 2015). Quality of
care in the ICU is central to hospitals and health systems given the volume of patients and their
severity of illness. The growth of ICUs since the 1950’s has outpaced many other divisions of
the industry, spurring the creation of professional societies like the Society of Critical Care
Medicine (SCCM) to ensure high quality care to the critically ill and injured individuals treated
in ICUs (Ward et al., 2013). The SCCM created an ICU Liberation Collaborative in response to
this mission, to prevent the debilitating effects of historic care approaches in the ICU that led to
PICS (Boehm et al., 2016; Davidson et al., 2013; Ely, 2017; Myers et al., 2016).
Post-ICU Syndrome (PICS)
The ICU cares for patients with the highest severity of illness throughout the hospital.
Admission into the ICU poses a significant impact on patient long-term morbidity and mortality,
due to prolonged sedation utilization and immobility, resulting in a condition identified as post-
ICU syndrome, comprised of a debilitating condition known as ICU delirium and ICU-acquired

19

weakness (Boehm et al., 2016; Davidson, 2013; Ely, 2017; Myers et al., 2016). Occurring in as
many as 80% of ICU patients, both ICU-delirium and ICU-acquired weakness often goes
undetected and untreated, threatening an individual’s physical, mental, and cognitive
independence long after discharge, ultimately accounting for $164 billion in health care costs and
loss of productivity in the United States annually (Ely, 2017). The impact of ICU-delirium is
linked to high rates of morbidity and cognitive impairment in all patient populations and can be
prevented and managed with approaches like the ABCDEF bundle (Ren et al., 2017).
ABCDEF Bundle Evidence
The ABCDEF bundle design was based on previous evidence-based quality bundle that
demonstrated an increase in the quality of patient outcomes. Built on the marked success of
previous evidence-based approaches to CLABSI (Pronovost et al., 2006), ventilator bundles
(Resar et al., 2012), and the Pain, Agitation, and Delirium (PAD) guidelines (Barr et al., 2013;
Devlin et al., 2018) the ABCDEF bundle was designed to combine the benefits of these previous
bundle approaches and evidence-based practices together to mitigate the post-ICU syndrome,
reduce cost, and drive high quality and efficient care in the ICUs. The ABCDEF bundle benefits
have been shown to meet these original design objectives. A review and meta-analysis of 21
studies illustrated that a decrease in mortality and ICU length of stay were statistically more
likely when implementing the ABCDEF bundle. (Trogrlić et al., 2015). Additionally, during an
eighteen-month study across five adult ICUs, patients’ post-implementation of the ABCDEF
bundle presented with a reduction in delirium, an increase in breathing without assistance by
three days, and were mobilized during their time in the ICU (Balas et al., 2014). These positive
results were further emphasized in a retrospective study of 159 patient records across the
University of Maryland Shore Regional Health system aimed at quantifying the prevalence of

20

delirium before and after implementing the ABCDEF bundle. Results showed a statistically
significant reduction (38% to 23%, P = .01) in the duration of delirium in ICU patients (Bounds
et al., 2016). A substantial reduction in hemodynamic indicators (P < 0.05) was observed in a
cross-sectional controlled study on 143 patients divided into two distinct groups (Pandharipande
et al. 2017). Moreover, the benefits of the ABCDEF bundle are evident across healthcare system
levels, from highly specialized academic medical centers, to community health centers (Barnes-
Daly et al., 2017). In this study, the investigators noted a correlation between increased bundle
compliance and improvement in survival rates.
ABCDEF Implementation Barriers
Despite the conclusive evidence supporting the bundled approach and necessitating its
implementation, the bundled protocol has not been widely adopted. A meta-analysis of
implementation strategies associated with managing ICU-delirium across 21 studies,
demonstrated statistically lower mortality and reduced ICU length of stay when a framework like
ABCDEF bundle was implemented (Trogrlic et al., 2015). In this systematic review, the authors
found that regardless of these broadcasted results and broad endorsement from various
professional societies and safety organizations, patients around the world were not receiving the
ABCDEF bundle as a standard of care in the ICU (p.157). Additionally, a survey administered to
212 respondents across the Michigan state health systems verified that only 12% had
implemented the ABCDEF bundle, regardless of conclusive evidence behind the approach
(Miller et al., 2015). Similarly, a study across six different hospitals in Texas reported the same
challenges, noting the application of the bundle was inconsistent regardless of the proof of
improvement in patient outcomes in the ICU (Masica et al., 2015). Translating the positive
research evidence produced by practicing the ABCDEF bundle into routine daily practice

21

remains a challenge in critical care. Studies performed in recent years detail the many stumbling
blocks to increased and sustained bundle compliance in the ICU.
Evidence shows there are multiple challenges to delivering the ABCDEF bundle in
critical care, irrespective of the compelling evidence of improvement in the quality of patient
care and outcomes. Edward et al. (2017) point to cultural barriers and clinicians historical
practice undermining the need for change. Other studies offer the following as challenges to
adopt evidence-based practice, including: (a) the number of steps in a bundle, and its
multidisciplinary nature (Resar et al., 2012); (b) the need for consistent communication across a
number of individuals, individual perception, and inadequate sources to access evidence (Grol &
Grimshaw, 2003); and (c) the need for reliable infrastructure, institutional cultural
considerations, and resistance to change (Boehm et al., 2016; Jordan et al., 2016).
Flawed bundle design. Even with the evidence supporting the ABCDEF bundle use,
there are concerns with the complexity of the bundle’s design as a barrier to its adoption. The
Institute of Healthcare Improvement (IHI) released a white paper in 2012 to summarize the
effectiveness of a bundle approach to improving care across these complexities (Resar et al.,
2012). Focused on the ICU, the study evaluated the implementation strategy of two separate
bundles in 13 hospital’s ICUs and proceeded to list guidelines for developing and implementing
healthcare bundles. Their bundle design guidelines include six recommendations, of which the
ABCDEF bundle does not strictly follow, implying a flawed bundle design.
The ABCDEF digresses from the concepts developed by its bundle predecessors, where
simplicity and minimal steps are encouraged. For example, the ABCDEF bundle is comprised of
six bundle elements that rely on one another, while the IHI’s recommendations state that more
than five bundle elements may be too complicated to lead a reliable implementation. This

22

experience was based both on the CLABSI bundle, where adoption of the 5-element bundle was
widespread, but was often only partial; an issue as lower CLABSI rates were observed in sites
with high whole bundle compliance (Furuya et al., 2016).
IHI also urged bundle creators to ensure each bundle element can be performed
independently of one another, while being measured in a discrete fashion. In direct opposition to
the IHI recommendations, the ABCDEF bundle requires sequenced delivery, and lends to a level
of ambiguity by giving clinicians a choice on how to approach each element. These anomalies
may be the source of the difficulties in comprehension and variation in interpretation of the
ABCDEF bundle.
Practice variance. The complexity of the ABCDEF bundle can give rise to variation in
interpretation of how to deliver its elements and in what sequence. In their qualitative and
multidisciplinary study, Boehm et al. (2016) noted a variation in the understanding of provider
roles in the ABCDEF bundle among practitioners and concluded elimination of this ambiguity
was crucial to increasing bundle compliance. The authors continue to highlight (a) hospital
culture; (b) inter-professional team dynamics; (c) time constraints; (d) the need for
multidisciplinary coordination, as cultural impediments to fulfilling bundle requirements.
Similarly, Leguelinel-Blache et al. (2018) observed in their two-year trial across two ICUs, that
clinical management of patients remained variable even with the implementation of best practice
protocols within specific bundle elements. These results were further underlined in a separate
study using an anonymous questionnaire responded to by 108 ICU nurses in Italy (Pinto &
Biancofiore, 2016). Their results confirmed while the clinicians were aware of elements within
the bundle and their known results to improve patient outcomes, in the ICU only 34% considered
the ABCDEF bundle applicable within their ICUs. 71% of respondents identified that the

23

protocols for elements B and D in the bundle were easy to comprehend and useful, but 48%
reported they did not employ these in daily practice. Given these results, Pinto & Biancofiore
(2016) stress that successful implementation of the ABCDEF bundle will require significant
improvement to education and a shift in culture.
Interprofessional team dynamics. The culture of care delivery broadly in healthcare is
hierarchical and has typically been performed within silos of each clinical discipline (Alexanian
et al., 2015; Manthous & Hollingshead, 2011). A siloed approach has led to lack of
communication that increases the probability of medical errors. The smallest error in the ICU can
lead to fatality due to the critically ill nature of patients in the unit, contributing to a highly
emotional environment (Ervin et al., 2018; Manthous & Hollingshead, 2011). Due to the critical
nature of patients, the clinical team in the ICU needs to be prepared to respond to unexpected and
rapid changes in the patient condition from their various levels of expertise in a coordinated
fashion (Alexanian et al., 2015; Donovan et al., 2018; Ervin et al., 2018; Manthous &
Hollingshead, 2011).
Implementation of ABCDEF bundle requires patient care coordination across the clinical
team which includes Physicians, Nurses, Physical and Occupational Therapists, Respiratory
Therapists, Nurse Practitioners, Pharmacists, Case Managers and Social Workers (Bassett et al.,
2015; Barnes-Daly, Phillips & Ely, 2017; Barnes-Daly et al., 2018; Boehm et al., 2016; Boltey et
al., 2019; Bounds et al., 2016; Hermes et al., 2018; Kram et al., 2015). Collaboration among the
group is a key shift in culture and approach needed to be successful in ABCDEF bundle
implementation. Altering care delivery from siloed care to team-based interprofessional care has
shown improvement in patient outcomes in the ICU (Donovan et al., 2018; Ervin et al., 2018;
Manthous & Hollingshead, 2011) and beyond. Scientific evidence proposes that building a team

24

culture could bridge the quality chasm described by the IHI (Briere, 2001; Manthous &
Hollingshead, 2011). Literature further suggests that fostering teams with effective collaboration
is linked with the ability to translate evidence-based care into practice and create a culture
focused on continuous improvement (Alexanian et al., 2015; Manthous & Hollinghead, 2011).
This was demonstrated in the VAP bundle, where Crunden et al. (2005) showed use of the
bundle demonstrated improved multidisciplinary communication. Regardless of the substantiated
evidence, supporting the benefits of teamwork in healthcare, adoption of team-based care is
known as a challenge (Ervin et al., 2018; Valentine et al., 2015). Effective teamwork is not
currently integrated within clinical curriculum (Ervin et al., 2018; Manthous & Hollingshead,
2011).
Compliance monitoring. Access to data is necessary to understand the status of bundle
implementation and course correct in real-time. Data and reports are needed to provide feedback
on performance and support continuous quality improvement is difficult to attain from the
current clinical information technology (IT) systems (Barnes-Daly et al., 2018; Bassett et al.,
2015; Proctor et al., 2015; Pun et al., 2019). Compliance measurement is fundamental to
sustaining implementation to any quality care bundle (Bassett et al., 2015; DeMellow & Kim,
2018; Resar et al., 2012). In 2011, the IOM suggested investment in healthcare information
technology was crucial to achieving the core goals of increasing the safety and efficacy of care
and ensuring healthcare delivery was patient-centered and equitable (Glandon et al., 2013).
Availability of actionable data of outcomes can bridge knowledge gaps and foster care
collaboration across the interprofessional team (Ervin et al., 2018; Pun et al., 2019). Achieving
sustained implementation and ongoing compliance monitoring is a challenge with the ABCDEF
bundle, due to the burden of data collection, amount of data missingness, lack of ability to

25

customize the electronic medical record (EMR), and inability to provide clinical decision support
(Basset et al., 2015; Barnes-Daly et al., 2018; Collinsworth et al., 2014). Improved compliance
and adoption of the ABCDEF bundle is driven by the availability of data to understand
performance and discuss status across the Clinical Team (Collinsworth et al., 2014). Availability
of data needs to be near real-time and coupled with the ability to read, interpret, and take action
on the data provided (Bassett et al., 2015). Successful adherence to the ABCDEF bundle requires
readily available information in real-time with education and training on the use of clinical IT
systems to bolster data quality and foster collaboration across the Clinical Team (Collinsworth et
al., 2014; Masica et al., 2015; Pun et al., 2019).
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework
To reach the Critical Care Center’s goal to implement evidence-based practice on 95% or
greater of patients in the ICU by March 2021, the organization will need to anticipate barriers
and design internal processes to mitigate potential performance gaps. Clark and Estes (2008)
designed a conceptual framework used to diagnose the root causes of a differential between
organizational goals and achievement through knowledge, motivational, and organizational
factors. This framework or problem-solving process, known as a gap analysis, begins with
understanding individual’s goals against the organization’s goals. Proceeding with identifying
assumed performance influences in the areas of knowledge, motivation, and organization based
on general theory, context-specific literature, and an existing understanding of the organization.
The gap analysis leverages Krathwohl’s (2002) knowledge characterization including factual,
conceptual, procedural, and metacognitive knowledge types. These types are linked to
motivational dimensions known as utility value, self-efficacy, goal orientation, and attribution
(Clark & Estes, 2008; Rueda, 2011). Clark and Estes (2008) gap analysis incorporates an

26

assessment of organization culture and its impact on knowledge, motivation, and improvement
efforts toward goal achievement.
Stakeholder Knowledge, Motivation, and Organizational Influences
The following section reviews the literature pertaining to the application of the Clark and
Estes (2008) gap analysis in the Critical Care Center’s implementation of the ABCDEF bundle.
The knowledge, motivation, and organizational influences necessary for the critical care clinical
team to achieve the goal of ABCDEF bundle delivery on greater than or equal to 95% of patient
cases were outlined. Attaining this goal directly aligns with the Critical Care Center’s
overarching goal to implement evidence-based practice on 95% or greater of patients in the ICU.
Knowledge and Skills
The complexity of the ABCDEF bundle requires knowledge and skills in complex
clinical practices that necessitates performance in daily succession on ICU patients to achieve the
maximum benefit to patient outcomes (Barnes-Daly et al., 2018; Ely, 2017; Pun et al., 2019).
Clark and Estes (2008) note that a gap in knowledge of how to effectively perform tasks, in this
case each element of the ABCDEF bundle, will hinder the organization’s ability to reach their
objective of applying this care approach to all ICU patients. To ensure effective adoption of new
tasks and achievement of organizational goals, knowledge deficiencies must be addressed (Clark
& Estes, 2008). The following section reviews the literature as it relates to the critical care
Clinical Team and the knowledge needed to successfully implement the ABCDEF evidence-
based quality bundle. Knowledge influences are characterized by three knowledge types,
including declarative, procedural and metacognitive.
Knowledge Influences. Applying a uniform framework to assess knowledge influences
provides the basis for common understanding of objectives and expectations of learning

27

(Krathwohl, 2002). A systematic approach to developing an individual’s knowledge and skills
will foster improvement across individuals, teams and organizations (Aguinis & Kraiger, 2009).
These systematic methods are crucial for healthcare improvers to overcome the well-known
resistance to change prevalent in the healthcare community that arises from the lack of
knowledge (Lucas & Nacer, 2015).
Krathwohl (2002) describes knowledge dimensions in a taxonomy of educational
objectives that include declarative factual and conceptual comprehension, procedural ability, and
metacognitive awareness. Declarative factual knowledge lends to the familiarity of specific facts,
while declarative conceptual knowledge relates to the relationship between factual details.
Procedural knowledge outlines the techniques and methods for how to perform a task, and
metacognitive knowledge encompasses awareness of one’s own cognition, strategic thinking,
reflection, and self-knowledge. Comprehension of the ABCDEF bundle was categorized into
Krathwohl’s (2002) taxonomy in order to apply a systematic approach of analysis that will
provide synthesis and evaluation of the learning processes that the clinical team will need to
develop to deliver the bundle in daily practice.
Declarative Knowledge Influence. Understanding of each of the ABCDEF bundle
elements, the role of each member of the clinical team, and how they are interrelated are needed
as a foundation of knowledge to implement the bundle as processes of care. These specific facts
must also be followed by a conceptual grasp of the interconnectivity of each element. Along with
the link between performance, documentation, and the production of accurate compliance
reports.
Basis of each element along with the roles and responsibilities. The ABCDEF bundle is
an acronym describing individual clinical interventions that are designed to occur in sequence.

28

The elements include: A for the assessment of pain; B for Spontaneous Awakening Trials (SAT)
and Spontaneous Breathing Trials (SBT); C for choice of analgesia and sedation; D for delirium;
E for early mobility and exercise; and F for family and patient engagement (Marra et al., 2017).
These elements were based on multiple known interventions, which are proven to mitigate poor
patient outcomes that have a life altering impact on the quality of life of a patient long after they
leave the hospital (Barnes-Daly, 2018; Boehm et al., 2016; Pun et al., 2019). The comprehension
of specific clinical processes of each bundle element is needed as declarative factual knowledge
and a foundational influence to executing the bundle protocol.
Connection between the bundle elements and the need to sequence them. The
arrangement of the bundle as an interprofessional practice is classified as declarative
conceptual knowledge. To accommodate this knowledge influence, the Clinical Team will
need to become acquainted with the notion of bundle care, that the success of the bundled
approach is dependent on applying interventions in a coordinated fashion, and that the team’s
consistent interactions are fundamental to achieving their compliance targets (Donovan et al.,
2018; Resar et al., 2012). The expertise as a multidisciplinary clinical team is known to be
the catalyst of bundle implementation (Kram et al., 2015). Bassett et al. (2015) note that a
key principle for understanding and adoption of the ABCDEF practice involved a
concentration on the interrelationship of the elements and sequential delivery to patients.
Link between protocol algorithms, documentation, and compliance measurement. The
importance of collective practice and consistent communication for bundled care has a clear
relationship to compliance results and is a central declarative conceptual knowledge influence.
The method for bundled care measurement is known as an “all-or-none” assessment that
emphasizes the significance of delivering the entire bundle to a patient, barring clinical reasons

29

to withhold the delivery due to the patient’s condition (Resar et al., 2012). The accuracy of
compliance reports is contingent upon daily, sustained, and appropriate documentation of
protocol implementation (Resar et al., 2012). Diligence in documentation is a vital conceptual
knowledge influence for the Clinical Team to demonstrate their progress toward achieving their
95% compliance goal. Additionally, documentation of compliance lends itself to the ability to
evaluate knowledge transfer and retention of the ABCDEF bundle protocol against all four levels
of evaluation noted by Kirkpatrick (2006) including reaction (level 1), learning (level 2),
behavior (level 3) and results (level 4). The Kirkpatrick model is widely used across many
industries to evaluate the effectiveness of training efforts (Aguinis & Kraiger, 2009). Measuring
reaction, learning, behavior and the patient outcomes results specific to the four levels will
provide an understanding of the transfer of knowledge to all members of the Clinical Team.
Procedural Knowledge Influence. The declarative knowledge influences are the basic
information required to understand the technique of how to deliver care. In the case of the
ABCDEF bundle, how to implement each element’s protocol as a whole, coordinate care,
interpret compliance, and take action to improve are procedural knowledge influences necessary
to achieve the Clinical Team’s compliance targets. Recognizing how to perform these steps in
concert to reach ABCDEF bundle compliance for every patient, is complex and often considered
a barrier to the Clinical Team for successful implementation (Barnes-Daly et al., 2018; Boehm,
et al., 2016; Boehm et al., 2017; Costa et al., 2017; Grol & Grimshaw, 2003; Jordan et al., 2016;
Resar et al., 2012). Careful consideration of implementation design is required to increase
efficiency and nurture a culture of learning and improvement across clinicians (Lucas & Nacer,
2015).

30

How to implement the protocol for each element, and the ABCDEF bundle in
sequence. Knowing the basic principles of each element must be coupled with expertise in how
to execute each related procedure to demonstrate daily compliance of the bundle. The ABCDEF
bundle combined is more complex than applying each element individual evidence-based
processes (Marra et al., 2017). Despite this fact, partial compliance has yielded significant
improvement in patient outcomes (Barnes-Daly et al., 2018; Costa et al., 2017; Pun et al., 2019;
Trogrlić et al., 2015). Knowledge on how to design the training and education on the protocol for
each element and the ABCDEF bundle as a whole, is crucial to the success of achieving partial
or complete bundle compliance. Assessing knowledge and understanding the needs of the
Clinical Team at the onset of implementation will aid in designing a customized approach to
training for implementation of the bundle (Aguinis & Kraiger, 2009). The customized approach
must take into account cognitive load theory, with special attention toward incorporating
automaticity within the design of training and education to increase cognitive efficiency and
allow for fewer cognitive resources needed for daily delivery of bundle care (Schraw &
McCrudden, 2006). Given the ABCDEF bundle’s six element approach, considering cognitive
load theory may ease the burden of learning and adopting six processes of care in an already
complex ICU environment.
How to perform multidisciplinary patient rounding for care coordination. Inter-
professional team dynamics played a significant role in enhancing bundle awareness, with the
multidisciplinary team expertise as the central facilitator of ABCDEF bundle implementation
(Boehm et al., 2017; Boehm, et al., 2016; Kram et al., 2015). The nature of the bundle
necessitates multidisciplinary team work and ongoing communication on the status of care of the
patient, demanding a shift in the historic silos of practice within each discipline (Barnes-Daly et

31

al., 2018; Bassett et al., 2015; Boehm et al., 2017; Boehm, et al., 2016; Coles et al., 2017; Costa
et al., 2017; Donavan et al., 2018; Ericksson & Mullern, 2017; Manthous & Hollingshead, 2011;
Pun et al., 2019). Implementation strategies will need to address this paradigm shift by
incorporating both multimodal staff education, and practice application of multidisciplinary
rounds that emphasize consistent use of bundle interventions for all ICU patients daily (Donavan
et al., 2018; Kram, et al., 2015).
An additional strategy to address this knowledge influence is the incorporation of
elements of sociocultural learning theory; that is, to embed practice learning of ABCDEF within
the social settings of multidisciplinary rounds which are integrated within the Clinical Team’s
daily workflow (Marsh & Farrell, 2015). The sociocultural learning theory approach facilitates
the community of practice necessary to establish a team culture of providing feedback, nurturing
questioning and dialogue, and brokering corrective strategies for bundle element interventions.
Incorporating sociocultural learning theory is important to mitigate the barriers posed by siloed
interprofessional team dynamics. Evidence demonstrates that applying a team approach in the
ICU increases the quality of patient outcomes (Donovan et al., 2018; Ervin et al., 2018;
Manthous & Hollingshead, 2011).
Read, understand and monitor compliance and patient outcomes reports, and connect
this to action plans. The Clinical Team will actively need to know how to understand data
reports and translate this to changing outcomes. The availability of data plays an essential part
to healthcare delivery and managing quality and performance (Bassett et al., 2015; DeMellow
& Kim, 2018; Marsh & Farrell, 2015; Ozcan, 2008; Resar et al., 2012). Placing meaningful
information in the hands of the Clinical Team will provide the explicit and implicit criteria
needed to establish accountability for adherence to the ABCDEF bundle (Emanuel, 1996).

32

Measuring compliance is the initial step in establishing a reliable system for protocol delivery
(Resar et al., 2012). The measures alone will not increase performance (Marsh & Farrell, 2015);
the clinical team lack the time, proficiency, and tools to manage the amount of data they need for
patient care and systematic improvement (Ervin et al., 2018). Providing the measures will need
to be paired with training and education in documentation, data literacy and knowledge
management to provoke action from the Clinical Team (Bassett et al., 2015; Collinsworth et al.,
2014; Ervin et al., 2018; Kram, et al., 2015; Marsh & Farrell, 2015). Demonstrating how to take
action with the data received in ABCDEF bundle compliance reports will establish the relevance
of data to the Clinical Team and promote a common understanding and practice towards
improvement of bundle delivery. Bassett et al., (2015) noted that frequent feedback with
compliance reports, followed by re-training, were vital in establishing a sustained commitment to
the implementation of the bundle.
Metacognitive Knowledge Influence: Reflect on the Clinical Team’s effectiveness at
delivering the bundle. Another category of knowledge types includes metacognition, described
as an individual’s ability to think strategically and be conscious of why and when a task requires
completion (Krathwohl, 2002; Rueda, 2011). Sustainable performance of the ABCDEF bundle
dictates the need for awareness on behalf of the Clinical Team, in their daily adherence to bundle
protocol. A current barrier to achieving consistent ABCDEF bundle delivery is the availability of
reliable and near real-time reporting that illustrates compliance performance (Barnes-Daly et al,
2018; Bassett et al., 2015; Collinsworth et al., 2014; Ely, 2017; Kram et al., 2015; Pun et al.,
2019). Accessibility of data by all clinical disciplines cultivates the interprofessional
collaboration to monitor, reflect, communicate, and perform the bundle interventions
(Collinsworth et al., 2014; Pun et al., 2019). Reflection is necessary for both the individuals and

33

the team of practitioners together to recognize the role personal or group performance has on
compliance to the ABCDEF bundle.
Table 2 illustrates the knowledge influences and their associated type, and assessment in
worksheet format. The worksheet begins with the organizational mission, global goal, and
specific stakeholder goal, followed by the knowledge influences relevant to achieving each
level’s set goal.
Table 2
Knowledge, Motivation, and Organization (KMO) Worksheet: Knowledge
Knowledge Influence Knowledge
Type
Knowledge Influence Assessment
The Clinical Team needs to know
the basis of each element along with
the roles and responsibilities
required for implementation.
Declarative
(Factual)
The Clinical Team was asked to
complete a formative and summative
assessment delivered electronically to
report clarity of their role in
implementation and support from their
administration and leadership.
The Clinical Team needs knowledge
of the connection between the
bundle elements and the sequential
order of elements.
Declarative
(Conceptual)
Each individual on the clinical team were
competency validated by the clinical
educator that trained them on bundle
elements and total bundle compliance.
This validation was documented in the
employee record.
The Clinical Team needs to
understand the link between protocol
algorithms, documentation, and
compliance measurement
Declarative
(Conceptual)
The Clinical Team was asked to ensure
documentation of process and protocols
were entered in the electronic medical
record (EMR) or other support tools. The
researcher will use ABCDEF compliance
reports as a proxy measure to audit for
appropriate documentation. If
compliance is low, a deep dive into
missing data was performed. Members of
the Clinical Team were re-educated on
appropriate documentation and its
importance.
The Clinical Team needs knowledge
of how to implement the protocol for
each element, and the ABCDEF
bundle in sequence.
Procedural The compliance of the unit and each
individual patient were used as a proxy
measure for adoption and knowledge of
the ABCDEF bundle. Each bundle
element was measured for compliance on

34

each patient, each day. The Clinical
Team was asked to review compliance
and seek re-education if results were
below target.
The Clinical Team needs knowledge
of how to perform multidisciplinary
patient rounding and how to use
rounding as a source for care
coordination and review of the
ABCDEF bundle for each patient.
Procedural The Clinical Team was observed and
audited by a member of administration
and re-educated when rounding did not
follow the standard template or
convention created. Individual members
of the Clinical Team were asked to
complete a formative and summative
assessment delivered electronically and
on paper feedback posted in the unit to
report changes in culture, and whether
they experienced an increase in
interprofessional collaboration. The
result of these assessments was used to
assess interprofessional collaboration.
The Clinical Team needs to be able
to read, understand, and monitor
compliance and patient outcomes
reports, and connect this to action
plans that will increase compliance
across roles.
Procedural The Clinical Team was asked to meet
biweekly to review reports and discuss
challenges and strategies to improve
compliance. Compliance reports were
used as a proxy measure to indicate
successful ABCDEF bundle compliance
improvement interventions.
The Clinical Team needs to reflect
on their effectiveness at delivering
the bundle using compliance reports.
Metacognitive The Clinical Team was asked to
complete a formative and summative
assessment delivered electronically to
self-evaluate their experience and
performance with the ABCDEF bundle.

Motivation
Adoption of the ABCDEF bundle in practice remains low across the medical community,
despite the evidence of the benefits to patient outcomes achieved when the ABCDEF bundle is
employed in daily practice (Barnes-Daly et al., 2018; Boehm, et al., 2016; Costa et al., 2017;
Masica et al., 2015; Miller et al., 2015; Trogrlić et al., 2015). Knowledge is needed to execute
tasks, while motivation is the stimulus that drives task engagement (Mayer, 2011). Therefore, the
combination of knowledge and motivation is the impetus for achieving bundle adoption in daily
practice and translating evidence-based medicine into practice. Knowledge and motivational

35

influences are tightly linked and pairing the two in implementation approach will increase the
likelihood of goal attainment (Clark & Estes, 2008; Rueda, 2011). Imparting the knowledge
needed to adhere to the ABCDEF bundle protocol will need to be combined with considerations
for the Clinical Team’s motivational influences to reach the 95% compliance goal for both the
organization and the critical care stakeholder group. The following section analyzes the
motivational influences that affect the ABCDEF bundle adoption through the lens of the
following theories: expectancy value and self-efficacy.
Expectancy Value Theory. The premise of expectancy value theory stems from the
concept that choice, determination, and function are explained by an individual’s belief system
and the perceived utility value of the activity (Wigfield & Eccles, 2000). The level of importance
applied to a task will drive choice, diligence and engagement toward task or goal achievement
(Wigfield & Eccles, 2000; Rueda, 2011). The Clinical Team will need to identify the value of
delivering the ABCDEF bundle to patients, and believe they possess the ability to attain
compliance goals according to the construct of expectancy value theory in order to translate
evidence-based protocol into practice.
Understand the value of adopting the ABCDEF bundle. Approximately five million
patients in the United States annually are admitted the ICU (Ervin et al., 2018; Pun et al., 2019).
Historic approaches to ICU healthcare delivery have placed patients at risk for debilitating and
life altering consequences (Marra et al., 2017). The need to redesign ICU care has become
progressively more significant given the percentage of critically ill patients and the rising cost of
care across the United States (Bassett et al., 2015; Lucas & Nacer, 2015). According to Lucas
and Nacer (2015), “Healthcare will not reach its full potential unless change making becomes an
intrinsic part of everyone’s job, every day, in all parts of the system” (p. 6).

36

Evidence demonstrates that implementation of the ABCDEF bundle significantly
improves patient outcomes and decreases expenditures, aligning with the Institute for Healthcare
Improvement’s (IHI) triple aim initiative to improve care, health and cost (Bassett et al., 2015;
Berwick, Nolan & Whittington, 2008; Whittington, Nolan, Lewis, & Torres, 2015). Due to the
gains observed when studying ABCDEF bundle implementation, professional societies and
critical care experts advise that the evidence-based bundle become a standard of care for all ICU
patients (Kram et al., 2015). Presenting the known benefits to the patients and the ability of
multiple clinical teams to reach partial and whole bundle compliance, will meet the basic needs
of the expectancy value motivational influences considerations to drive engagement in ABCDEF
bundle adoption.
Self-Efficacy Theory. The construct of self-efficacy theory delves further into the need
for an individual to believe in their ability to achieve their objectives (Bandura, 2000; Pajares,
2006). This theory ties directly to an individual’s confidence in their capability, propelling them
to realize their ambitions (Clark & Estes, 2008; Rueda, 2011). Pajares (2006) describes four
sources of self-efficacy beliefs known as: mastery experience that include successful
experiences; vicarious experience comprised of observing success and failure of others; social
persuasions involving external praise; and physiological reactions that take into account
emotional states. Studies suggest that high self-efficacy is linked to increased self-regulation,
persistence and enhanced memory performance, while low self-efficacy can cause stress and
anxiety that inhibit task completion (Pajares, 2006; Rueda, 2011). Systematic change in
healthcare is often met with resistance, either due to political considerations or the absence of
clinician’s motivation to modify practice regardless of the overwhelming change benefits. If
opposition does not fall into these two categories, it lies within the miscommunication and

37

the inability to coordinate interprofessional patient care. Overall, change is difficult, and any
adjustment that requires advanced collaboration is challenging (Grol & Grimshaw, 2003;
Lucas & Nacer, 2015). As a multidisciplinary group, the Clinical Team must develop their
individual self-efficacy to progress toward a shared belief in the impact of their joint action,
defined as collective efficacy (Bandura, 2000). Both self-efficacy and collective efficacy can
coexist, a key factor in fostering the motivation of the Clinical Team to jointly adhere to the
ABCDEF bundle and utilize this evidence-based protocol into daily practice.
Capable of achieving compliance targets, interpreting compliance reports, and taking
action. ABCDEF bundle compliance is reliant on the Clinical Team’s actions in concert, this
required interdependencies demonstrates the high degree of collective efficacy needed for the
team to achieve their shared compliance target (Bandura, 2000). This alignment across the
individuals of the Clinical Team is pertinent to reaching compliance targets, evaluating
performance leveraging compliance reports, and taking the action needed to improve daily
adherence to all bundle protocols including ABCDEF (Barnes-Daly et al., 2018; Boehm, et al.,
2016; Boehm et al., 2017; Collinsworth et al., 2014; Costa et al., 2017; Ervin et al., 2018; Grol &
Grimshaw, 2003; Jordan et al., 2016; Resar et al., 2012). Research reveals that implementation of
the ABCDEF bundle has led to increased staff satisfaction, due to the shift in culture toward
coordinated care practice across disciplines, and the significant improvement in patient outcomes
(Kram et al., 2015; Marra et al., 2017). The increase in staff satisfaction is directly linked to the
four sources of self-efficacy, implying that implementation of the ABCDEF bundle itself will
provide ongoing reinforcement of motivation for the individual and collective team to reach the
stakeholder compliance goals.

38

Table 3 displays the motivation influences and their assumed type, and assessment in
worksheet format. The worksheet begins by restating the organizational mission, global goal, and
specific stakeholder goal. This is followed by the motivational influences relevant to achieving
each level’s set goal.
Table 3
Knowledge, Motivation, and Organization (KMO) Worksheet: Motivation
Assumed Motivation Influences Motivational Influence Assessment
Utility Value: The clinical team
needs to understand the value of
adopting the ABCDEF bundle in
daily practice
Written survey item “I feel the ABCDEF bundle improves
patient care” (5-point Likert scale). Measure compliance to
the protocol from the electronic medical record.
Additionally, written survey items: “I feel the ABCDEF
bundle improves patient care” (5-point Likert scale); “I feel
the implementation of the bundle (increased, decreased,
didn’t affect) patient outcomes.”

Self-Efficacy: The clinical team
needs to believe they are capable of
achieving compliance targets,
interpreting compliance reports, and
taking appropriate action needed to
improve ABCDEF bundle
compliance
Paper feedback posted in the unit to report what staff
believed are causes of low compliance. Written survey
items: “Using data in patient care and management is a good
idea; Using data in patient care and management is
unpleasant; Using data is beneficial to my patient care and
management; I feel ABCDEF bundle compliance improved
with the implementation of AF compliance reports; Overall,
I find the AF compliance reports useful in managing my
compliance to the ABCDEF bundle; The AF compliance
reports helped me understand what actions I needed to take
to improve my implementation of the ABCDEF bundle” (5-
point Likert scale)
Organizational Influences
Understanding a culture and how it influences knowledge and performance improvement
is an essential component of driving an organization’s evolution (Schein, 2017). Incorporating
sustained change in existing organizational culture is essential to successful transformation
(Kezar, 2011). The dynamic healthcare environment needs sustainable change to accommodate
new scientific evidence being produced by researchers at a rapid cadence (Briere, 2001; Drolet &
Lorenzi, 2011; Edward et al., 2017). To keep up with ongoing change, Lucas and Nacer (2015)

39

suggest improving and sustaining performance continuously in healthcare requires forming
habits of action and cannot not solely rely on the attainment of knowledge and skills. Basset et
al. (2015) note that addressing culture across clinical disciplines is essential to ICU performance
and practice change, and critical to the adoption of the ABCDEF bundle. The implementation of
the ABCDEF bundle itself necessitates a cultural shift from silo-based care delivery to
multiprofessional coordinated care (Marra et al., 2017). Deeming the consideration of social and
cultural contexts of the ICU setting vital for adoption of the bundle (Costa et al., 2017). The
culture of healthcare delivery across the medical community is cited as a prime factor to change
opposition and adoption of evidence-based practice (Basset et al., 2015).
Cultural Models. Culture can be described as the shared values, beliefs, and rules of
behavior in an organization (Schein, 2017). These shared beliefs or mental models conflict with
new initiatives, underlining the importance of uncovering mental models that may prevent or
undermine adoption of change (Senge, 1990).The process of discovering these models can be
problematic, as social structure is not visible and is often imperceptible (Senge, 1990). The
ABCDEF bundle is a direct challenge to the cultural models of clinicians, requiring practice
change, collaboration across individuals, and new conventions for care delivery (Costa et al.,
2017; Grol & Grimshaw, 2003; Hermes et al., 2018). The following section analyzes the cultural
models that affect ABCDEF bundle implementation including practice change and trust across
the Clinical Team.
A culture of acceptance to change existing practice to adopt the ABCDEF bundle.
Change resistance dominates the healthcare industry, rooted in fear-based emotions, and deep-
rooted opposition to change (Lucas & Nacer, 2015). Producing a guideline or policy is not
enough to instigate change and confront the firmly held care delivery philosophies of clinicians

40

(Edward et al., 2017). Knowledge of research evidence that support practice change have not
been enough to alter established practice (Grol & Grimshaw, 2003; Masica et al., 2015; Miller et
al., 2015; Trogrlic et al., 2015). Even when clinicians acknowledge the value of adhering to the
ABCDEF bundle, only a small percentage believe it to be applicable in their own ICU (Pinto &
Biancofore, 2016). The underlying question of applicability of the ABCDEF bundle may be
based on the persistent culture of individualized practice that undermine collaboration across
disciplines. Application of the bundle requires executing each of the elements in a coordinated
approach across the disciplines within the Clinical Team (Pun et al., 2019). Sustainable delivery
of high-quality care is fundamentally supported by teamwork and communication (Resar et al.,
2012). A collaborative, care coordinated approach is at odds with the caste system that has
dominated healthcare operations historically and in present day (Manthous & Hollingshead,
2011). Multiprofessional coordination of healthcare delivery has been cited as a barrier to bundle
adoption (Boehm et al., 2016). Imparting the knowledge to adhere to the bundle, combined with
a focus on positive patient outcomes as a motivation to reproduce improved value (Barnes-Daly
et al., 2018; Hermes et al., 2018) is a tactic that may be used to shift the mental models toward
the coordinated care model required to support ABCDEF bundle adherence. A culture that
adopts change, as opposed to resists its merits is needed to translate new evidence-based
protocols into practice.
Culture of trust in order to achieve interprofessional practice. Quality and trust are
directly related to performance improvement (Berwick, 2003). Therefore, trust is the focal point
of sustainable change and fundamental to the ability to translate evidence into daily practice
among clinicians. The responsibility of healthcare change relies on the providers that deliver it,
eliciting the need for implementation plans that address developing trust across clinical

41

disciplines (Berwick, 2003). In their review of five hospitals, Basset et al. (2015) illustrate that
effective implementation of the ABCDEF bundle focused on interdisciplinary teamwork that
fostered trust and drove culture change. However, the emotional healthcare environment caused
by high rates of mortality in the ICU, challenge creating an atmosphere of trustworthy behavior
(Berwick, 2003; Ervin et al., 2018). To foster an environment of effective teamwork, the
multidisciplinary team must feel protected and empowered to actively coordinate the care of
patients across cultural hierarchies within an emotionally charged landscape (Manthous &
Hollingshead, 2011). Compliance performance on quality bundles can be used as an indicator to
evaluate the shift in culture, as work behavior is considered a predictor of trust between leaders
and staff (Korsgaard, Brodt & Whitener, 2002). A culture of trust is needed to bolster
performance and establish an environment conducive to the collaboration required to implement
evidence-based medicine.
Cultural Settings. If cultural models are the shared mental schema of an organization,
they can be revealed through the cultural setting indicators known as daily norms, rules, or
institutional policy (Schein, 2017). To overcome the resistance to practice change, the Clinical
Team will need to foster an environment of shared learning, trust, and collaboration through
formal policy and informal practice patterns that are supported by culture (Berwick, 2003;
Donovan et al., 2018; Manthous & Hollingshead). The section below discusses a subset of the
cultural settings that affect ABCDEF bundle implementation including the need for dedicated
time for training and education, as well as, support from the leadership for the Clinical Team.
Clinical team needs time to receive the appropriate amount of training and education
on the bundle. Senge (1990) specified that achieving exceptional performance is reliant on
learning. In healthcare, competing priorities, lack of time, support resources, confidence and

42

comprehension are barriers to creating a learning culture (Lucas & Nacer, 2015). Boehm et al.,
(2017) observed time constraints as a key impediment to reaching ABCDEF bundle compliance
targets. The Clinical Team will need dedicated support and time to learn how to implement the
elements of the entire bundle, including the impact of appropriate sequencing of each bundle
element (Basset et al., 2015). A multimodal approach to education is crucial to effective bundle
implementation (Kram et al., 2015). Without this, ambiguity in roles and responsibilities and a
variation in bundle delivery will affect the organization’s ability to reach compliance targets
(Boehm et al., 2016; Leguelinel-Blache et al., 2018). The Critical Care Center will need to
provide adequate time for staff training and education to ensure high compliance performance on
the ABCDEF bundle.
Clinical Team need organization leadership to support the integration of the ABCDEF
bundle into practice. Approval, support, and dedicated resources from leadership is fundamental
to creating an environment that supports the changes needed to adhere to the ABCDEF bundle
(Kram et al., 2015). The integration of new practice with high reliability necessitates redesigning
infrastructure, workflow, communication, and resources for sustained integration in daily
practice (Resar et al., 2012). A lack of administrative engagement in bundle delivery was noted
as one of the common barriers identified across studies focused on ABCDEF bundle
implementation. This lack of commitment manifested itself as lack of allocation of staff for
education, compliance monitoring, and support for continuous improvement (Barnes-Daly et al.,
2018; Pun et al., 2019). To accommodate shifts in cultural norms, policy, and daily practice for
ABCDEF bundle implementation, the leadership of the Medical Center will need to endorse the
bundle and provision the appropriate resources to meet the Clinical Team and Critical Care
Center’s goals.

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Table 4 lists the organizational influences and assessment in worksheet format. The
worksheet begins with the organizational mission, global goal, and specific stakeholder goal,
followed by the organizational influences relevant to achieving each level’s set goal.
Table 4
Knowledge, Motivation, and Organization (KMO) Worksheet: Organization
Assumed Organizational Influences

Organization Influence Assessment
Cultural Model Influence 1: The organization
needs to facilitate a general acceptance and
willingness among the Clinical Team to
change existing practice to adopt the
ABCDEF bundle.
Document review evaluating the ABCDEF
bundle compliance performance of the
Clinical Team was used to assess practice
change
Cultural Model Influence 2: The organization
needs a culture of trust across the disciplines
within the Clinical Team in order to achieve
the interprofessional practice necessary for
adherence to the ABCDEF bundle daily.

Survey questions: “interprofessional
collaboration increased with ABCDEF
bundle implementation; collaboration
improved across disciplines with the
implementation of the ABCDEF bundle.”
The compliance of the unit and each
individual patient was used as a proxy
measure for establishing trust, as ABCDEF
bundle requires teamwork and trust across
individuals in the Clinical Team.
Cultural Setting Influence 1: The
organization needs to give the Clinical Team
time to receive the appropriate amount of
training and education on each bundle
element, and the bundle’s application as a
whole.
Survey questions: “I feel I received too little
training on (A, B, C, D, E, F, The entire
ABCDEF Bundle); I feel I received more
training than necessary to perform (A, B, C,
D, E, F, The entire ABCDEF Bundle)”
Cultural Setting Influence 2: The Clinical
Team needs organization leadership to
support the integration of the ABCDEF
bundle into practice.
Survey questions: “I received the support I
needed from the administration team
throughout the implementation of the
ABCDEF Bundle; My department provides
all of the tools I needed to be successful to
perform this bundle”

44

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
Conceptual frameworks are theories, concepts, assumptions, and beliefs that provide a
guide for researchers to construct a study design and derive meaning from the results (Maxwell,
2013). They can also be described as the structure of the study that orients all sections to the
problem statement and purpose of the research by guiding sampling strategy, data collection, and
analysis (Merriam & Tisdell, 2016). The conceptual framework that guides this research study is
based on the Clark and Estes (2008) gap analysis framework, which identifies the underlying
causes for organizational performance gaps as they relate to knowledge, motivation, and
organization influences. Each of the knowledge, motivation, and organization (KMO) influences
of this study were identified from sources in the literature that outline the outcomes, challenges,
and areas for future research for ABCDEF bundle protocol implementation. The scope of this
study includes key influences indicated in the literature but is not inclusive of all potential
influencers.
Influences of Focus
The knowledge needed to adopt the ABCDEF bundle as a new practice was straight
forward and consistent across the literature. Evidence noted that adopting new practices requires
factual knowledge of the protocol, the concept of sequencing elements, how to deliver the
bundle, and monitor compliance performance to ensure effective delivery (Barnes-Daly et al.,
2018; Boehm et al., 2016; Collinsworth et al., 2014; Pun et al., 2019). Each of these influencers
were included in this study to analyze the knowledge needs of the Clinical Team as the Critical
Care Center embarked on implementing the ABCDEF bundle protocol. The illustration in Figure

45

1 demonstrates that all knowledge influences are pertinent to the green circle, which represents
the Clinical Team as the stakeholder of focus.
Four motivational factors were identified from existing evidence that relate to utility
value (Wigfield & Eccles, 2000), self-efficacy (Pajares, 2006), goal orientation (Yough &
Anderman, 2006), and attribution (Anderman & Anderman, 2006) theories. Given that the
Critical Care Center is at the onset of integrating the ABCDEF bundle into ICU practice as a
standard of care, the study focuses on two of the four motivational factors most relevant to this
phase, i.e., utility value and self-efficacy. The initial planning phases focus on engaging the staff
in changing practice and learning a new method for care delivery. Both utility value and self-
efficacy focus on this phase of implementation, while the goal orientation and attribution
motivational influences not included in the study target post implementation performance and
sustained adoption of the ABCDEF bundle. Figure 1 shows the motivational influences in the
green circle representing the Clinical Team’s knowledge and motivational influences, pointing
with an arrow toward reaching the Critical Care Center’s goal in the yellow rectangle.
A number of organizational influences were cited in the literature as necessary for
ABCDEF bundle adoption, placing emphases on historic practice undermining change (Edward
et al., 2017), the need for a cultural shift to multidisciplinary practice (Boehm et al., 2016; Jordan
et al., 2016), robust technology to monitor compliance (Collinsworth et al., 2014), a general
willingness of clinicians to standardize practice (Leguelinel-Blache et al., 2018), and an
organizational environment that incorporates family engagement (Ely, 2017). Like the
motivation influences, because the Critical Care Center is at the initial phase of ABCDEF bundle
adoption, the influences chosen for the study focus on those relevant to that phase, including the
willingness of the Clinical Team to change practice, the trust needed for collaborative care

46

delivery, the support of organizational leaders, and the dedicated time to learn the new method to
care delivery. These are key organizational elements in the conceptual framework represented by
the blue circle in Figure 1. Figure 1 exhibits the Clinical Team as the stakeholder within the
Critical Care Center as the organization, depicting the interplay between the organizational
influences, and knowledge and motivation influences of the stakeholder required to move toward
the goal of ABCDEF bundle implementation.
Influence Interplay
As shown in Figure 1, each of the potential influencers do not impact the organization in
isolation. The conceptual framework outlines the overlapping nature of the KMO influences that
impact achieving the Critical Care Center’s goal to achieve ABCDEF bundle delivery on greater
or equal to 95% of patients in the ICU. Four examples distinctly illustrate the interrelationships
across the influences. The first two examples lie in the intersection of the knowledge influences
of the Clinical Team in the green circle, and the organizational influences of the Critical Care
Center in the larger blue circle. The first example establishes that the cultural setting of the
organization needs to allow time for clinicians to participate in training and education (Lucas &
Nacer, 2015). Therefore, to attain the factual, conceptual, and procedural knowledge surrounding
ABCDEF bundle adoption to reach compliance targets, the Clinical Team need appropriate
training. This concept is supported by Senge (1990), in his claim that performance is reliant on
learning. Additionally, the second example shows, procedural knowledge on how to perform
multidisciplinary rounding for care coordination confronts the cultural setting that needs to shift
from silo care delivery to collaboration across disciplines (Boehm et al., 2016; Pun et al., 2019).
The third and fourth example concern the relationship between the Clinical Team’s knowledge
and motivation influences within the green circle. The Clinical Team may lack the motivation to

47

attain new knowledge due to competing priorities and time constraints (Boehm et al., 2017),
even if the cultural setting supports the education necessary to attain knowledge. Also, if the
clinical team does not maintain consistency across the factual and procedural knowledge of
individuals they will not be able to achieve the compliance targets (Leguelinel-Blache et al.,
2018), regardless of whether they are motivated by value and self-efficacy. These examples
indicate that the KMO influences work in isolation, but also can interact in a variety of ways
toward achieving the overall goal of ABCDEF bundle adherence.
Figure 1
Conceptual Framework: Practice Change in Critical Care

48

49

Summary
This innovation study seeks to understand the KMO influences (Table 5) that impact
translating the latest evidence-based practice in critical care into daily practice. The study design
was informed by a literature review to develop a thorough understanding of the challenges in
translating evidence-based practice in the healthcare industry, the quality improvement efforts to
bridge the quality chasm described by the IOM (Donaldson et al., 2000), the emergence of
bundled care delivery as a performance improvement effort, and how the bundled care delivery
manifested itself in the critical care domain with the ABCDEF bundle protocol. Developing this
understanding, led to the use of Clark and Estes (2008) conceptual framework to identify the
KMO influences related to achieving ABCDEF bundle adoption required from a
multidisciplinary clinical team for effective delivery. The knowledge influences reviewed the
declarative, procedural, and metacognitive needs of the Clinical Team to effectively integrate
ABCDEF bundle protocol in practice. The motivation influences focused on the understanding
of the value of the bundle, and the belief that the Clinical Team is capable of successfully
reaching ABCDEF bundle compliance targets. The organization influences outlined the cultural
models and settings required at the onset of the Critical Care Center’s implementation of
ABCDEF bundle including the trust needed, the willingness to change practice, the support of
leadership, and the dedicated time for training and education. The conceptual framework these
KMO influence framed were reviewed independently and in concert, concluding with a
discussion of the complex interplay across the KMO influences. Chapter three will outline the
methodological approach taken to validate the KMO conceptual framework’s relevance in
reaching the Critical Care Center’s goal.

50

Table 5
Summary Table of Assumed Influences on Performance
Stakeholder Assumed Influences on Performance
Knowledge Motivation Organization
• Clinical Team needs to know
the basis of each element
along with the roles and
responsibilities required for
implementation.
• Clinical Team needs
conceptual knowledge of the
connection and sequencing of
bundle elements.
• Clinical Team needs to
understand the link between
protocol algorithms,
documentation, and
compliance measurement.
• Clinical Team needs
knowledge of how to
implement the ABCDEF
bundle protocol in sequence.
• Clinical Team needs
knowledge of how to perform
multidisciplinary patient
rounding as a source for care
coordination and review of
the ABCDEF bundle.
• Clinical Team needs to be
able to read, understand and
monitor compliance and
patient outcomes reports, and
connect this to action plans
that will increase compliance.
• The Clinical Team needs to
reflect on their effectiveness
at delivering the bundle.
• Clinical Team needs
to understand the
value of adopting
the ABCDEF bundle
in daily practice.
• Clinical Team needs
to believe they are
capable of achieving
compliance targets,
interpreting
compliance reports,
and taking
appropriate action
needed to improve
ABCDEF bundle
compliance.

• The organization needs to
facilitate a general
acceptance and
willingness among the
Clinical Team to change
existing practice to adopt
the ABCDEF bundle.
• The organization needs a
culture of trust across the
disciplines within the
Clinical Team in order to
achieve the
interprofessional practice
necessary for adherence
to the ABCDEF bundle
daily.
• The organization needs to
give the Clinical Team
time to receive the
appropriate amount of
training and education on
each bundle element, and
the bundle’s application
as a whole.
• The organization needs to
support the Clinical Team
to integrate the ABCDEF
bundle into practice.

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Chapter Three: Methods
Translating evidence-based research into daily practice is a challenge in healthcare. This
is no exception in critical care, where an evidence-based quality bundle, known as the ABCDEF
bundle, has been difficult to adopt in the ICU despite the conclusive evidence of its benefits to
patient care. The objective of this innovation study was to understand the knowledge, motivation,
and organizational influences related to reaching the stakeholder goal of 95% implementation of
the ABCDEF bundle by March 2021. This chapter gives a detailed overview of the participating
stakeholders, the research design, methodology, data collection and instrumentation, and high
level-description of the data analysis approach. The chapter concludes with an outline of the
validity and reliability, ethical considerations, and the limitations and delimitations of the study.
The research questions that guided the study included:
1. What is the ICU Clinical Team’s knowledge and motivation related to implementing
the ABCDEF bundle on greater than 95% of ICU patient cases within the Critical
Care Center?
2. What is the interaction between the Critical Care Center’s culture and context and the
ICU Clinical Team’s knowledge and motivation related to implementing the
ABCDEF bundle on greater than 95% of ICU patient cases within the Critical Care
Center?
3. What are the recommended knowledge, motivation, and organizational solutions?
Participating Stakeholders
The Critical Care Center mandated the ABCDEF bundle as standard practice in all ICUs
at the Medical Center, therefore the stakeholder of focus for the study included all members of
the Clinical Team responsible for care in the ICU in four of the eight ICUs at the Medical

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Center. A focus on four ICUs of differing specialties allowed for learning and application of new
knowledge on the KMO influences to the remaining ICUs. Inclusion of each discipline within
the Clinical Team was necessary as ABCDEF bundle compliance was reliant on the action of
each team member in coordination with one another. Both survey and document review methods
were used to validate the Clark and Estes (2008) gap analysis framework of KMO influences.
The criteria used for both methods are described in further detail in the following sections.
Survey Sampling Criteria and Rationale
Criterion 1
Any practicing member of the Clinical Team within all ICUs of the Critical Care Center
from the following clinical disciplines: Physicians, Nurse Practitioners, Nursing, Pharmacists,
Respiratory Therapists, Physical and Occupational Therapists, Nutritionists, Social Workers, and
Case Managers. Achieving ABCDEF bundle compliance targets required the coordinated action
of each discipline for every patient in the ICU. This criterion ensured the participants that were
required to achieve ABCDEF bundle compliance were included in the analysis.
Criterion 2
Four of the eight ICUs were included in the analysis to address the research questions.
The initial unit was included in the analysis, despite the pilot nature of the initial implementation.
Recommendations from the four units were used to improve the implementation approach on the
remaining four units.
Survey Sampling (Recruitment) Strategy and Rationale
The sampling strategy for the survey portion of the study was known as a census
sampling strategy. A census sampling approach includes the entire study population (Johnson &
Christensen, 2015). The four ICU’s of focus for the study within the Critical Care Center were

53

made up of approximately 386 staff members that encompassed the Clinical Team at the time of
the study. The researchers of the study had the time, ability, and access to include the entire
study population. Additionally, including all 386 staff members produced a larger sample size.
The larger sample size allowed for a more confident establishment of program effect (McEwan
& McEwan, 2003).
The CCC administration team sent a staff survey to all members of the Clinical Team
following the implementation of the ABCDEF bundle on each of the four ICUs to elicit their
feedback on the implementation and gauge the impact of the KMO influences (Appendix A).
The survey functioned as a formative assessment that was used to understand the effectiveness of
the education and adjust learning during implementation of the final units (Mayer, 2011). The
questions in the surveys also served as a summative assessment, to understand what the learner
acquired overall and recognize how they felt at the end of instruction (Mayer, 2011). The
researcher designed the formative and summative assessment questions to be a source of
information to answer the research questions posed by the study. Staff lists and contact
information for the Clinical Team was obtained from the CCC administration and leadership of
each unit.
Document Review Sampling Criteria and Rationale
Criterion 1
Compliance results from each of the four ICU’s of the CCC and the clinical staff that
were directly responsible for ABCDEF bundle practice included: Physicians, Nurse Practitioners,
Nursing, Pharmacists, Respiratory Therapists, Physical and Occupational Therapists, Social
Workers, and Case Managers. ABCDEF bundle compliance was measured by unit, not by the
individual staff members of the Clinical Team. Measurement of bundle compliance provided the

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Clinical Team’s performance toward the Critical Care Centers ABCDEF bundle compliance goal
of implementing the bundle on 95% of patients in the ICU.
Criterion 2
Compliance measurements were made on whether adult patients met criteria for bundle
element measurement and if clinical staff complied with the bundle elements. Thus, cases that
had the opportunity to have all bundle elements i.e., patients on mechanical ventilation for at
least 24 hours in any of the three ICUs, were measured as well as clinical staff actions to bundle
element component adherence. Pediatric patients were not be included as they are not a patient
population that is served by the Medical Center.
Criterion 3
Patients in the ICU for at least 24 hours were included in compliance measurement.
Measuring ABCDEF bundle compliance required a 24-hour period of data collection to assess
adherence to bundle practice. The bundle should have been applied daily to every patient in the
ICU unless contraindicated by the patient failing the ABCDEF Safety Screen or assessed by the
unit Intensivist.
Criterion 4
Compliance reports for the four ICUs of focus within the Critical Care Center from
October 2018 through October 2019 were reviewed. This time period captured results from each
unit both pre- and post-implementation of the ABCDEF bundle. The time period allowed for the
assessment of the Critical Care Center’s goal to reach 95% compliance to the ABCDEF bundle
across all ICUs.
Document Review Sampling (Access) Strategy and Rationale

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As with the survey strategy described above, document review utilized a census sampling
strategy. The same rationale of the survey sampling approach to include the entire study
population i.e., the benefit of a large sample size and capability of the research team to access the
entire sample, applied to the document review strategy. Document review included the
examination and analysis of ABCDEF bundle compliance reports for all four units as a whole.
The compliance reports for each ICU were computed and provided by the Critical Care Center’s
administration team on a weekly and monthly basis for the implementation period. The
compliance reports were used as proxy measures to answer the research questions of the study
and assessed the impact of the KMO influences on achieving the Critical Care Centers goal of
95% compliance to the ABCDEF bundle on all ICU patients.
Document review considered the waves of the stepped wedge ABCDEF bundle
implementation at the Critical Care Center (Appendix A). Each wave consisted of a month of
clinical education (M1) which included typical training on ABCDEF bundle followed by a
month of compliance monitoring (M2). Typical training followed the definition of ABCDEF
bundle training established by the Society of Critical Care Medicine’s (SCCM) ICU
liberation campaign (Pun et al., 2019). Month one and two follows a third month of data
literacy training (M3) and an additional month of compliance monitoring (M4). A data
literacy training convention was included by the Critical Care Center in response to the cited
barriers to ABCDEF adoption in the literature referring to compliance monitoring and
understanding (Bassett et al., 2015; Collinsworth et al., 2014; Pun et al., 2019). In addition,
compliance of all ICUs prior to M1, was assessed as a baseline measurement (M0) of
compliance. All ICUs compliance in aggregate were also analyzed at the end of the study

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period (Month 10) to evaluate compliance after implementation has occurred on all units of
focus.
Data Collection and Instrumentation
The primary methods of data collection chosen to support the quantitative nature of the
study were surveys and analyzing document and artifacts. The use of survey techniques were
used to gather staff perception of the ABCDEF bundle’s impact on organizational culture, as
well as understand any knowledge gained, and motivational factors that impacted their
performance. The survey design followed Creswell and Creswell’s (2018) description of a
surveys purpose to understand relationships between variables in a descriptive and predictive
manner over time. The document review technique was used to measure direct progress toward
the Critical Care Centers 95% ABCDEF bundle compliance goal, and whether having
compliance information during implementation elicits a response to increase performance. Both
of these approaches related directly to answering the research questions using quantitative
methods.
Observation of the stepped wedge cluster randomized implementation of the
ABCDEF bundle within the Medical Center’s ICUs provided the content of the gap analysis
for both the survey and document review analysis. Each unit at the Medical Center received
two interventions during the implementation of the ABCDEF bundle, described as follows:
1. Month 0 (M0): Planning and baseline compliance measurement.
2. Month 1 (M1): The first intervention was Usual Customary Care (UCC) that
included standard clinical education over a 1-month period.
3. Month 2 (M2): Compliance measurement with the ABCDEF bundle.

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4. Month 3 (M3): The second intervention was UCC plus data literacy training focused
on the use of compliance reports to aid in ABCDEF bundle compliance monitoring
and feedback (UCC + Tech).
5. Month 4 (M4): Compliance measurement with ABCDEF bundle with compliance
reported on a weekly basis.
An applied action research approach was applied to continuously observe, analyze,
and implement suggested actions (McEwan & McEwan, 2003; Stringer, 2014) to improve
ABCDEF bundle compliance as the bundle was implemented in each ICU. Leveraging action
research allowed the application of potential improvements observed in real-time to increase
adherence of the bundle. Increased compliance to the ABCDEF bundle was associated in the
literature with an increase in the quality of patient outcomes (Barnes-Daly et al., 2018; Ely,
2017; Pun et al., 2019).
Surveys
Survey Instrument. The survey maintained two demographic questions for each of
the four survey engagement points, with a total of 42 survey items. Of the 42 survey
questions, 14 assessed knowledge, 8 reviewed motivation, 17 evaluated the organization
influences, and one was posed as an open comment question. Survey questions were derived
from literature describing job satisfaction measurement in healthcare (Chang et al., 2017),
assessing the safety climate in healthcare (Flin et al., 2004) and reviewing the technology
acceptance model (Davis, 1989; Davis et al., 1989; Holden & Karsh, 2010; Hu et al., 1999).
As in the evidence-based survey samples, the majority of the questions on the study survey
use a Likert scale response to assess the opinion of the Clinical Team as related to the KMO
influences. The Likert scale response allowed for measuring attitudes on a particular topic

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(Robinson & Leonard, 2019). Seven confidence intervals questions were also included in the
survey. Confidence intervals record the assuredness of individuals belief in their efficacy on a
100-point scale (Bandura, 2006). In field tests with the survey, survey duration was
approximately five to seven minutes for each point of engagement. Appendix B lists the
survey protocol for each of the four surveys.
Survey Procedures. The surveys administered were leveraged as assessment tools to
grasp the individual’s understanding and quality of performance of the ABCDEF bundle, as well
as evaluate the acceptance and satisfaction of the change management strategies for
implementation to increase the ABCDEF bundle adoption as an institutional standard of ICU care
delivery. The survey approach included gathering feedback at the end of the intervention
period (M1-M4) for any given unit. Survey questions were designed to allow the researcher
to understand and compare the KMO influences at multiple time points during the
implementation approach. Comparing approaches, such as UCC and UCC + Tech allowed
the researcher to understand which intervention, if any, contributed to gaps in KMO that
prevent the organization from reaching their performance goals. Survey analysis was
completed concurrently with the document review that detailed each unit’s actual
performance toward the ABCDEF bundle compliance goal. A detailed timeline of the
implementation illustrating the interventions and survey engagement is outlined in Appendix
A.
Members of the Critical Care Center administrative team disseminated the surveys to
each unit using an online link or QR code through the Qualtrics survey platform. An
electronic method of delivery allowed for inclusion of all 386 members of the Clinical Team,
and real-time monitoring of survey response rates. Low response rates found during

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monitoring provided the impetus for the Critical Care Center’s Administrative team to enact
additional engagement strategies to increase response rates. For example, survey respondents
from each unit were offered an opportunity to enter a raffle to receive a small prize of movie
tickets equivalent to 40 dollars, provided by the Critical Care Center. Offering incentives
have been known to increase response rates (Pedersen & Nielsen, 2016; Guo et al., 2016).
Documents and Artifacts
ABCDEF bundle compliance was measured throughout the study to evaluate the
Critical Care Center’s progress toward achieving the 95% ABCDEF bundle compliance goal.
The Critical Care Center’s Analytics team obtained the bundle compliance reports from the
Medical Center’s clinical information technology (IT) systems, and analyzed according to the
compliance algorithms created by the SCCM ICU liberation campaign’s research
methodology and analysis (Barnes-Daly et al., 2018; Ely, 2017; Pun et al., 2019). More
specifically, quantitative analysis of the compliance reports were used as proxy measures for
the KMO influences needed to measure ABCDEF bundle performance.
Data Analysis
The researcher conducted descriptive statistical analysis once all survey results were
submitted. Frequencies were calculated, including means and standards deviation for confidence
interval questions to identify average levels of responses in relation to the conceptual framework
and study questions. The researcher analyzed documents and artifacts for evidence consistent
with the concepts in the conceptual framework. Document review included measurement of
bundle compliance for each of the protocol elements, along with the individual element
compliance in aggregate, as the ABCDEF bundle was implemented across the Critical Care
Center as a standard daily practice. Complete performance was measured by total bundle

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compliance; that was taking the total number of patients that received the ABCDEF bundle over
the total number of patients on the unit eligible for bundled care over a 24-hour period. Partial
compliance was defined as a percentage of bundle elements performed on any given day. Each
patient that received care from the Clinical Team was nested within a 24-hour period, then
within the ICU visit, then within the ICU. Baseline evaluation (M0 of the study) was made
and included as a covariate to estimate a time effect across the implementation period of all
ICUs. The sample size was determined by the number of ICU’s and members of staff in the
Clinical Team during the time measured. There were eight ICU’s with varied staffing
numbers according to number of beds and patient acuity. For the four ICU’s of focus in the
study, this led to an estimated 386 members of the Clinical Team (64 Physicians; 158 Nurses;
6 Nurse Practitioners; 128 Respiratory Therapists; 22 Physical and Occupational Therapists;
3 Case Managers; 3 Social Workers) engaged in study survey’s and document compliance
review across the units. On average, the ICU’s cared for 368 patients per month. This led to
an estimated 4324 patients with an opportunity to receive the ABCDEF bundle during the 12-
month implementation period across the four units (October 2018 - October 2019).
Validity and Reliability
Mitigating threats to validity and reliability was important to consider during study
design to guarantee the questions asked to respondents answered the research questions intended
(Robinson & Leonard, 2019). In this study, both the sampling methods and the survey approach
contribute to maximum validity and reliability. The census sampling approach for the survey and
document review worked together to eliminate selection or nonresponse bias. That is, regardless
of the survey response rate, all members of the Clinical Team practicing in the ICU cannot avoid
being included in the document review of bundle compliance. The KMO influences and progress

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toward the stakeholder goal was assessed from the document review of compliance performance,
in combination with the responses from the survey given at various points in time during
implementation. The strategy to reduce or eliminate bias mitigates the threat to validity via
selection (Creswell & Creswell, 2018) and promoted a high level of reliability in study analysis
(Krueger & Casey, 2014). The census sampling method to include all 386 members of the
Clinical Team across the ICU, promoted a large sample size. Recruiting a large sample size is a
primary mitigation strategy for the threat to validity via mortality (Creswell & Creswell, 2018).
The length of the study period and the nature of allocating the same staff member across
different ICUs introduced a threat to validity known as diffusion of treatment. To minimize this
threat, the researcher kept groups as separate as possible (Creswell & Creswell, 2018). The
researcher and the CCC administrative team did their best to blind the pending units to the details
of the implementation and education on the ABCDEF bundle. Participants were reminded not to
share experiences or results with units pending implementation for the duration of the study. In
addition, treatment diffusion was considered during the quantitative statistical analysis.
Survey questions used were a combination of questions derived from existing studies in
healthcare and additions from the researcher to further delve into the KMO influences. Members
of the Critical Care Center’s administrative team, four different clinicians, 15 members of the
ICU unit leadership, and a biostatistician with psychometric expertise reviewed and tested each
of the surveys prior to administration. Pretesting survey questions ensured the validity of the
survey by confirming questions are clear and easily understood by respondents (Robinson &
Leonard, 2019). The pretests confirmed that with a cycle of iteration, the final survey
instructions, items, and mode of delivery were clear and uniform. Confirming consistency in

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interpretation of the survey instructions and questions increased the reliability of the survey
(Salkind, 2017).
The survey was sent to all members of the Clinical Team that practice in the ICU at the
Medical Center over the 12-month study period. To ensure a high response rate and confidence
in results, each survey was disseminated electronically by the CCC Administrative team. The
CCC’s administrative team monitored response rates from the Qualtrics survey platform and
follow a multi-prong engagement strategy including: (A) email reminders to staff; (B) discussion
at staff meetings; (C) incentive to be enrolled in a raffle for a prize equivalent to 40 dollars per
unit; (D) unit visits to enlist individual staff members to complete surveys in real-time. This
engagement strategy was used to safeguard a high response rate, further reduce the risk of
nonresponse bias to the survey and promote validity of the data.
Ethics
Researchers maintain an ethical responsibility to safeguard patients from harm during
scientific studies (Rubin & Rubin, 2011). To uphold their ethical duties, the researcher obtained
study approval from the institutional review board (IRB) of the University of Southern California
(USC). The IRB was responsible for objective review of the risks to participants in the study,
ensuring the needs of vulnerable populations were met, and determining the need for informed
consent (Creswell & Creswell, 2018). Within the IRB application and the USC disclosure
system, the researcher stated any potential conflict of interest that affected the study given their
leadership position in the Medical Center and Critical Care Center. The researcher explained that
data collection and analysis was performed by members of the CCC administration team, and not
directly by the researcher given their leadership position in the CCC. Vested interest in outcomes
by the researcher given their position within the organization would not allow for the objectivity

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required for quantitative or qualitative research (Creswell & Creswell, 2018). Removing the
researcher from direct data collection and analysis, ensured their position would not influence or
introduce bias to the study. Both the IRB and the USC Office of Compliance needed to approve
the researchers’ role as principal investigator in the study and the design approach outlined in the
IRB application.
The CCC administrative team obtained implied consent from the ICU Clinical Team and
patients as the ABCDEF bundle was implemented across all ICU’s of the Medical Center as an
institutional standard of care and industry best practice protocol. Formal consent was
documented from multiple levels of the CCC’s leadership during meetings where the study
protocol was reviewed and approved prior to study launch. The data collection and analysis
methods were outlined during the consent process and within the IRB application.
Per the protocol, the ABCDEF bundle was applied daily to every patient in the ICU
unless contraindicated by the patient failing the ABCDEF Safety Screen or assessed by the unit
Intensivist (Ely, 2017; Marra et al., 2017; Pun et al., 2019). Thus, all members of the Clinical
Team were included in data collection. In the first phase of data collection, all members of the
Clinical Team were sought to respond to a survey following ABCDEF bundle implementation.
All data collected from the questionnaire was gathered anonymously. Anonymous collection of
the questionnaire ensured the right to privacy of all participants (Glesne, 2011). The second
phase of data collection included document review of ABCDEF bundle compliance of each ICU.
The document review data analysis method of ABCDEF bundle compliance remained at the ICU
level, ensuring individual members of the Clinical Team remained confidential. Analysis of the
questionnaire and ABCDEF compliance document review were completed by a study statistician
external to the CCC. The researcher designed the analysis approach to eliminate any

64

interpretation bias or influence from the researcher during document analysis (Merriam &
Tisdell, 2016).
The researcher fostered reciprocity (Glesne, 2011) by sharing results and
recommendations to improve performance on ABCDEF bundle compliance with the Medical
Center and Critical Care Center leadership and clinical Teams from all ICUs following the study.
The researcher shared the data as an investigator, disclosing during all presentations and report
disseminations that knowledge gained from the study was expressly used to improve
performance, not to evaluate the performance of an individual or ICU. The researcher was
straightforward, honest, and delivered all promises to uphold their ethical obligations (Rubin &
Rubin, 2011).
Limitations and Delimitations
Internal or external factors outside of the researcher’s control are known as limitations.
Several limitations were identified by the researcher, including:
• Nonresponse bias from surveys from specific clinical disciplines of the Clinical
Team.
• Clinical education approach to implementing the ABCDEF bundle was
determined and implemented by the Clinical Education Department of the
Medical Center. The Department may not have stayed consistent as they
implemented their education across the ICUs.
• Consistency of education across disciplines, for example a physician trainer on
one unit, may not have given the same level of detail or description regardless of a
standard presentation or script.

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• Compliance performance was dependent on whether the Clinical Team members
appropriately documented each intervention. If documentation was not completed,
this would reflect poorly on bundle performance, despite having fully executed
the bundle in practice.
• Clinical Team members not present or not receiving the standard bundle
education.
• New staff on the unit, including but not limited to, rotation of physician residents
and fellows.
• Technology limitations of the electronic medical record (EMR) to support easy
and appropriate Clinical Team documentation of ABCDEF elements once
performed.
• Shifts in the implementation timeline due to competing priorities or unforeseen
circumstances in the ICUs.
• Staffing model, that supported an individual assigned to multiple ICU’s at any
given time. A staff member may have been trained on ABCDEF bundle for
practice on one unit but transferred to another unit that has not received training
or vice versa.
• Treatment diffusion, meaning discussion of the implementation protocol and
education of individuals that have not received the formal ABCDEF bundle
implementation.
• Availability of staff for implementation activities during holiday and summer
months.

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• Patient census on the unit, and the amount of opportunities a single ICU has to
administer the ABCDEF bundle.
Delimitations were outlined as the decisions a researcher makes that have implications to
the data collected in the study. Delimitations of this study involved:
• Algorithm decisions made outside of the SCCM ICU Liberation Campaign’s
analysis approach may affect the ability to benchmark. These decisions included:
o Local Medical Center policies that provide more strict management of a
certain element, including: (A) A of ABCDEF bundle for the ICU
liberation campaign requires assessment of pain per ICU day, while the
Medical Center’s policy requires assessment per ICU shift with target pain
scores; (B) E of ABCDEF bundle requires a mobility assessment for the
ICU Liberation Campaign, while the Medical Center follows a detailed
mobility protocol that includes assessment and intervention management;
(C) F of ABCDEF bundle requires engagement of family once per ICU
admission for the ICU Liberation Campaign, while the Medical Center
requires daily family engagement.
• The decision to study the entire Clinical Team and all disciplines as opposed to
focusing on a single profession requires engagement from all staff may skew data
if nonresponse bias is high for any given discipline.
• Choosing a quantitative study design may limit the ability to derive meaning from
the data collected in surveys and document review.

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• Survey questions maintained a majority of Likert scale responses. Responses were
therefore more descriptive as opposed to evaluative, which could have led to
difficulty in interpretation (Robinson & Leonard, 2019).
• The researcher placed more weight during analysis on compliance performance
results than the survey responses collected during the study.

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Chapter Four: Results and Findings
The purpose of this innovation study was to measure the extent of knowledge and skill,
motivation, and organizational resources required to reach the sustainable implementation of
evidence-based best practice protocols on 95% or greater of ICU patients by December 2025.
Specifically, the study focused on reaching the stakeholder goal of 95% implementation of the
ABCDEF bundle ICU protocol by March 2021. An implementation plan was designed
incorporating the assumed influences itemized in Table 5 and represented in a conceptual
framework in Figure 1. Data was gathered by way of a survey and document review to validate
the assumed influences and explore any additional factors needed to achieve the stakeholder
goal. The analysis of the data outlined in this chapter reviews the participating stakeholders,
results, and findings in relation to the following research questions:
1. What is the ICU Clinical Team’s knowledge and motivation related to implementing the
ABCDEF bundle on greater than 95% of ICU patient cases within the Critical Care
Center?
2. What is the interaction between the Critical Care Center’s culture and context and the
ICU Clinical Team’s knowledge and motivation related to implementing the ABCDEF
bundle on greater than 95% of ICU patient cases within the Critical Care Center?
3. What are the recommended knowledge, motivation, and organizational solutions?
A quantitative approach using both a survey tool and document review were used to address
the research questions. The data collection for the survey included 42 survey items sent to 386
members of the Clinical Team from four ICUs at the Medical Center. The survey was sent
following the implementation of the ABCDEF bundle across all units. The survey took
approximately five to seven minutes to complete. The final analysis of the survey included 319

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members of the Clinical Team, resulting in an 83% response rate. In addition to the survey, a
document review was conducted. The document review leveraged the ABCDEF bundle
protocol compliance results as a proxy measure for the KMO influences needed to measure
ABCDEF bundle performance.
Participating Stakeholders
The stakeholder group of focus for the study consisted of multidisciplinary clinicians
from four distinct ICUs of the Medical Center. Multiple roles were included in the analysis as
partial and total ABCDEF bundle protocol compliance was defined by the action of each team
member in coordination with one another. Members of the Clinical Team of focus included
physicians, nurses, nurse practitioners, respiratory therapists, physical and occupational
therapists, case managers and social workers.
Survey Participants
Clinicians who practiced in the four ICUs during the study period were either sent a
survey by email or solicited directly in the ICU by members of the Critical Care
Administration team. A total of 386 individuals received a prompt to participate in the
survey. Of the 386 recipients, 319 individuals responded to the survey, resulting in an 83%
response rate. Figure 2 illustrates the survey response and distribution of Clinical Team
recipients by role, respondents by role, and the corresponding response rate for that role.
Appendix C details the survey recipients and respondents by role in table format. Variation in
response rate can be attributed to the number of recipients per role. For example, role groups
including physicians, nurses, respiratory therapists (RT), physical and occupational therapists
(PT/OT) had a large number of recipients ranging from 22 to 158, compared to nurse
practitioners (NP), case managers, and social workers with numbers ranging from 3 to 6. A

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response rate of 100% was more attainable for NPs, case managers, and social workers given
the small number of individuals needed for survey participation.
Response rates were calculated to assess the presence of nonresponse bias.
Nonresponse bias had the potential to threaten the validity of the study (Creswell & Creswell,
2018; Krueger & Casey, 2014). Pazzaglia et al. (2016) note that 85% is an appropriate
threshold for nonresponse bias. However, evidence in medical literature exploring low
response rates in studies with clinicians state that low response rate does not need to impact
the validity of a study (Templeton et al,. 1997). The researcher assumed nonresponse bias
was not present in the study given the proximity to the 85% threshold and the use of
mitigation strategies recommended by Templeton et al. (1997) to maximize validity in
clinical research studies. Mitigation strategies included appropriate data cleaning to
maximize validity.
Figure 2
Survey Distribution and Response

17%
41%
33%
6%
2%
1%
1%
1%
15%
48%
26%
7%
2%
1%
1%
1%
73%
97%
66%
95%
100%
100%
100%
100%
P HY S I CI A N N U R S E RT P T /O T N P CA S E
M A NA GER
S O CI A L
W OR K E R
O T HER
SURVEY RESPONSE AND DISTRIBUTION
Recipients by Role Respondents By Role Response Rate By Role

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Document Review
ABCDEF bundle protocol compliance was extracted from the Medical Center’s
electronic medical record (EMR). All clinicians that practiced in one of the four ICU’s and
documented in the patient’s medical record were included in the review. Compliance was
calculated using the algorithms created by the SCCM ICU liberation campaign’s research
methodology and analysis (Barnes-Daly et al., 2018; Ely, 2017; Pun et al., 2019). The Clinical
Team’s documented action on an individual element, as well as the bundle as a whole, were
used to understand the knowledge, motivation, and organizational influences for
implementation of the bundle in compliment with the survey administered.
Results and Findings
The following section reviews the results from the survey tool and document review used
to apply the Clark and Estes (2008) gap analysis in the Critical Care Center’s implementation of
the ABCDEF bundle. Surveys were administered at the end of the intervention period (M1-
M4) for each ICU as outlined in the timeline in appendix A. This included (1) clinical
education as the first intervention (M1) and measurement period (M2), known as post UCC;
(2) data literacy education as the second intervention (M3) and measurement (M4), known as
post UCC + Tech. Results are organized by the knowledge, motivation, and organizational
influences explored when the Medical Center attempted to implement the ABCDEF bundle in
four of their ICUs. Although categorized into single influences, many of the survey questions or
document review results can be applied to multiple influences. For the purposes of analysis, the
researcher chose to classify each result by the most relevant influence.
Table 5 outlines the assumed influences for each of the knowledge, motivation, and
organization influences studied. Figure 1 illustrates the conceptual framework that delineates the

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influence interplay across the assumed influences. The results were used to assess the assumed
influences as well as the efficacy of the stakeholders to reach their goal of achieving greater than
or equal to 95% compliance during the implementation of the novel patient care approach. The
results addressed data gathered between the October 2018 and October 2019 implementation
period of the ABCDEF bundle across four ICUs.
Knowledge Results
Multiple aspects of knowledge were assessed using both the survey tool and the
document review. Several questions on the survey were dedicated to assessing various aspects of
the knowledge influences related to adherence to the ABCDEF bundle protocol. The document
review used the Clinical Team’s compliance to the protocol as an indication of knowledge
gained over the implementation period. The results of the assessment are outlined within the
knowledge categories including declarative, procedural, and metacognitive knowledge.
Declarative Knowledge. Declarative knowledge was evaluated through a factual and
conceptual lens. Declarative factual knowledge examined familiarity of specific facts, and
declarative conceptual knowledge identified the relationships between factual details
(Krathwohl, 2002). The first assumed declarative knowledge influence was factual in nature and
tested the Clinical Team’s knowledge of the basis of each element and their roles and
responsibilities. The second assumed declarative knowledge influence was conceptual and
related to the connection between the bundle elements and the need to sequence them. Figure 3
provides the survey responses from the Clinical Team related to both the first and second
assumed declarative knowledge influence. Figure 3 shows in shades of green that 94% of
respondents had some level of agreement when asked if they understood their roles and
responsibilities during ABCDEF bundle implementation, with 76% either generally or strongly

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agreeing to this statement. This level of agreement implies the education approach during M1-
M4 was successful in imparting the assumed knowledge influences needed to implement the
bundle.
Figure 3
Factual Knowledge
The researcher continued to explore declarative conceptual knowledge through the
assumed influence relating to the link between protocol algorithms, documentation, and
compliance measurement. Figure 4 displays the six survey questions that addressed this assumed
influence. Three of the questions reveal that respondents believed using data in patient care was
both a good idea and beneficial with 92% and 90% strongly agreeing or agreeing respectively.
When asked if using data in patient care was unpleasant, 81% had a degree of disagreement
shown in shades of orange. Most respondents felt that having access to data was essential to
managing ABCDEF bundle compliance, with 87% in strong or general agreement. 84% of
respondents felt a level of agreement, displayed in shades of green, toward the use of compliance
reports assisting with performance management and improving ABCDEF bundle compliance.

27%
49%
18%
4%
1%
2%
I UNDERSTAND MY ROLE AND RESPONSIBILITIES FOR ABCDEF BUNDLE IMPL EM ENT A T I O N
FACTUAL KNOWLEDGE
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

74

These survey questions revealed that respondents felt data played a significant role in managing
ABCDEF bundle compliance.
Figure 4
Conceptual Knowledge
Procedural Knowledge. Two survey questions were used to evaluate whether the
Clinical Team possessed the procedural knowledge required to deliver the ABCDEF bundle. In
the first procedural knowledge question, members of the Clinical Team were asked to rate their
level of confidence in monitoring their unit’s compliance to the ABCDEF bundle. Confidence

52%
6%
50%
45%
26%
18%
40%
8%
40%
42%
38%
43%
5%
6%
7%
9%
20%
23%
1%
11%
1%
3%
8%
8%
0%
38%
1%
1%
4%
6%
2%
32%
1%
1%
3%
2%
USING DATA IN
PATIENT CARE
A N D
M A NA GEM ENT
IS A GOOD IDEA
USING DATA IN
PATIENT CARE
A N D
M A NA GEM ENT
IS UNPLEASANT
USING DATA IS
BENEFICIAL TO
MY PATIENT
CARE AND
M A NA GEM ENT
HAVING ACCESS
TO DATA IS
ESSENTIAL TO
M A NA GI NG
ABCDEF BUNDLE
CO M P LI A NCE
I FEEL THE A - F
CO M P LI A NCE
RE P O RT S
HELPED IN
MANAGING MY
P ER F O R M A NCE
WITH ABCDEF
BU N D L E
USING THE A - F
CO M P LI A NCE
RE P O RT S
IMPROVES MY
COMPLIANCE TO
THE ABCDEF
BU N D L E
CONCEPTUAL KNOWLEDGE
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

75

intervals record the potency of individuals’ belief in their efficacy on a 100-point scale with 10
intervals from cannot do as zero, to an intermediate level of certainty at 50, and a complete level
of conviction at 100 (Bandura, 2006). Figure 5 illustrates in shades of blue that 59% of
respondents reported a confidence interval of 61 or above, with a mean of 74.79, median of 80,
mode of 100, and standard deviation of 23.19 (Appendix D, Table 28). The median, mean, mode,
and standard deviation values indicate that the majority of the Clinical Team responded on the
upper spectrum of the confidence interval 0-100, with the value of 100 as the most frequent
response. These statistical results demonstrate that the majority of the Clinical Team felt a high
level of assuredness in how to monitor their unit’s adherence to the ABCDEF bundle. However,
the researcher noted 28% responded with low confidence to monitoring their unit’s compliance,
an area for improvement noted in recommendations listed in chapter 5. In contrast with the low
confidence reported by 28% of respondents to monitor compliance, the results of the second
question shown in Figure 6 confirms that 93% of respondents felt they possessed the skills they
needed to read and interpret data reports related to the ABCDEF bundle during implementation.
The 93% response to possessing the skill they need to manage compliance, paired with a 34%
drop to 59% confidence in monitoring their unit’s compliance imply a potential contradiction in
compliance monitoring. The Clinical Team felt they had the skills to read and interpret data
reports, but did not feel confidence in managing their unit’s ABCDEF bundle compliance which
signified to the researcher the need for improvement in the process of creating and providing
ABCDEF compliance reports.
Figure 5
Procedural Knowledge Confidence Intervals

76

Figure 6
Procedural Knowledge

2%
2%
1%
2%
10%
11%
8%
20%
14%
31%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Monitoring my unit's compliance to the ABCDEF bundle
PROCEDURAL KNOWLEDGE
CONFIDENCE INTERVALS
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

29%
47%
17%
5%
1%
1%
I FEEL I HAVE THE SKILLS TO READ AND INTERPRET DATA REPORTS
PROCEDURAL KNOWLEDGE
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

77

Metacognitive Knowledge. Five questions on the survey asked members of the Clinical
Team to reflect on their abilities as it related to learning and implementing the ABCDEF bundle.
Three questions took the form of confidence intervals, while two questions applied Likert scales.
Figure 7 shows 83% of respondents felt a high level of certainty regarding the ease of learning to
perform the bundle. In addition, the confidence level of respondents to read and interpret data
reports increased by 15% following participation of data literacy training. Like the procedural
knowledge results, the detailed statistics shown in Table 6 support the survey participants
maintained a high level of assuredness across the three confidence level questions. Each question
shows a mode of 100, signifying that the majority of respondents felt the highest level of
confidence for each question. The mean, standard deviation, and interquartile data for questions
Q17_5 and Q17_7 denote that most respondents felt an intermediate or high level of assuredness.
Some variation was seen in question Q17_4 where the mean drops to 73.07 and the interquartile
Q1 drops to 55. The lower values compared to Q17_5 further support that data literacy training
increased the Clinical Team’s ability to read and interpret ABCDEF bundle reports.
Table 6
Metacognitive Knowledge Statistics

Q17_4 Q17_5 Q17_7

Ability to Read and
Interpret ABCDEF
Data Reports Before
Data
Ability to Read and
Interpret ABCDEF
Data Reports After
Data Literacy
Training
Learning How
to Perform the
Bundle was
Easy for Me
Calculation Value Value Value
Mean 73.07 81.59 81.59
Median 79.00 87.00 85.50
Mode 100.00 100.00 100.00
Variance 506.18 330.48 304.62
Standard
Deviation 22.50 18.18 17.45
Minimum 0.00 0.00 15.00
Maximum 100.00 100.00 100.00
Range 100.00 100.00 85.00

78

Q1 55.00 74.00 70.00
Q2 79.00 87.00 85.50
Q3 90.00 95.00 100.00
Q4 100.00 100.00 100.00
Interquartile
Range 35.00 21.00 30.00

Figure 7
Metacognitive Knowledge Confidence Intervals
When asked to reflect on the ability to understand data, Figure 8 confirms that 91% of
respondents had a level of agreement shown in shades of green, in their aptitude to understand
data. Figure 8 also shows that 81% of survey participants felt the presence of ABCDEF bundle
compliance reports improved their ability to interpret data. The results of the metacognitive
knowledge survey questions highlight the need for data on protocol compliance for members of

2%
1%
0%
1%
0%
1%
2%
0%
0%
3%
1%
0%
13%
6%
5%
10%
5%
10%
9%
9%
10%
18%
16% 16%
20%
27%
22%
24%
34%
35%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Ability to read and interpret ABCDEF
data reports BEFORE data literacy
training
Ability to read and interpret ABCDEF
data reports AFTER data literacy
training
Learning how to perform the bundle
was easy for me
METACOGNITIVE KNOWLEDGE
CONFIDENCE INTERVALS
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

79

the Clinical Team to reflect on the effectiveness of their performance on ABCDEF bundle
practice.
Figure 8
Metacognitive Knowledge
Document Review. The document review included evaluation of the Clinical Team’s
protocol compliance over a period of one year. Figure 9 visualizes the ABCDEF bundle protocol
compliance between October 2018 and October 2019. The graph displays the compliance of the
four ICUs studied in red, against the remaining four ICUs that did not receive the ABCDEF
bundle implementation. The vertical dotted lines signify the go-live date of the intervention on a
specific unit. For example, the Surgical Intensive Care Unit (SICU) in blue received the M1
Clinical Education intervention in January of 2019 and the M3 data literacy training in late-
March. The horizontal black dotted line shows the SCCM national average of 18% compliance
following the ABCDEF bundle implementation across 67 sites in the United States (Pun et al.
2019). The initial three months of the time period were recorded to provide a baseline

24%
17%
50%
40%
17%
24%
7%
10%
2%
6%
1%
3%
I FEEL ABLE TO UNDERSTAND DATA RELATED TO
THE ABCDEF BUNDLE
A -F COMPLIANCE REPORTS IMPROVED MY
ABILITY TO INTERPRET DATA
METACOGNITIVE KNOWLEDGE
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

80

measurement for compliance prior to any intervention on the units. Both the live units that
received ABCDEF bundle implementation M1 – M4, and the non-live units that did not
participate in the implementation during the time period experienced a statistically significant
increase in ABCDEF bundle compliance (live units p< .0001; non-live units p = .005). Statistical
significance is reported as p < .05 (Salkind , 2017). The four ICUs that received the M1-M4
ABCDEF bundle implementation interventions increased their bundle compliance by 17% by the
end of the study period, and also exceeded the national average benchmark by 17%.
Despite not receiving ABCDEF bundle implementation interventions, the non-live unit
increase in bundle compliance was also significant. This can be attributed to members of the
Clinical Team that practice across multiple units. These staff members received the ABCDEF
bundle implementation training on the live units and likely applied it to their patient care practice
on all units. This social phenomenon, known as the Hawthorne effect, is described as the
unintended effect of the experiment operation (Cook, 1962).
Statistically significant improvement was also achieved for each of the individual
processes of care required for each element of the bundle. Appendix G contains detailed graphs
of protocol compliance to each of the ABCDEF bundle elements along with ABCDEF bundle
compliance by unit. For example, Figure 24 in Appendix G shows that the process of care to
manage the F element for Family engagement in the ABCDEF bundle increased from 55.8%
compliance to 83% resulting in p < .0001. Although the ICUs did not meet the stakeholder goal
of 95% compliance, these results suggest that the Clinical Team gained the knowledge necessary
to increase their adherence to the ABCDEF bundle.
Cross refencing the compliance results with the survey revealed some skepticism by
survey respondents on the validity of the compliance results. A theme found in the open

81

comments section of the survey divulged some concern on the parts of respondents that not all
individuals were documenting appropriately. One respondent claimed they felt “the data
implemented and the improvement in patient care does not reflect our compliance numbers.” A
second participant supported this claim by stating “charting bundle compliance is an extra step
for nursing. Charting and feedback from reports are inaccurate. The data is flawed. We have
greater complaisance than the data suggests.” The researcher chose to continue to use and
heavily weight the compliance results, given that appropriate documentation was included in the
clinical education interventions at both M1 and M3. Emphasis on the connection between how
the Clinical Team documented in the EMR to performance on the ABCDEF bundle was
reiterated during both interventions and included in the assumed influences.
Figure 9
ABCDEF Bundle Protocol Compliance
Knowledge Influence Summary. The survey results combined with the document
review demonstrated that the Clinical Team acquired the knowledge needed to increase the
ABCDEF bundle compliance with statistical significance. However, the researcher identified

82

room for improvement across all knowledge influences in order to bridge the gap between
Clinical Team performance and their goal. At the end of the study period, the Clinical Team
across the four ICU’s had achieved 31% compliance to the ABCDEF bundle as whole, but the
stakeholder goal based on IHI’s recommendations on quality bundle utilization was 95% (Resar
et al., 2012).
Table 7 outlines the assumed knowledge influences and classifies them as a strength or
weakness according to the survey results combined with the document review of compliance
results. Despite the increase in compliance, three procedural, one conceptual, and one factual
knowledge influence were identified as weaknesses given the gap from actual performance and
stakeholder goal. ABCDEF bundle compliance can be considered an artifact of knowledge, as it
is a direct measure of whether the Clinical Team has the knowledge to execute the bundles
processes of care (Clark & Estes, 2008). The nature of bundle compliance assumes that if you
have procedural knowledge on how to perform the bundle you maintain declarative and
conceptual knowledge.
The 64% gap between actual performance and stakeholder goal may be explained by a
gap in procedural knowledge that impacts the associated declarative knowledge influences. This
is demonstrated by the compliance results of each individual process of care. Appendix G shows
higher compliance for each individual element compared to the ABCDEF bundle compliance as
a whole. For instance, Appendix G, Figure 21 for bundle element C displays the Clinical Team’s
ability to maintain above 85% for the processes of care associated with C. The discrepancy
between the individual element compliance compared to the bundle as a whole indicates a lack
of knowledge on how to implement each bundle element in the appropriate sequence to meet
whole bundle compliance goals. In spite of survey responses, the differential in individual

83

element and whole bundle compliance found in the document review also implies that the
Clinical Team may not have enough knowledge of their roles and responsibilities required for
implementation, and the concept of sequential ordering. The researcher has given more weight to
the document review than the positive responses given by Clinical Team members in the survey
results because the compliance results from the document review are a direct measurement of
maintaining the knowledge needed to execute the bundle. Although the increase in compliance
demonstrates knowledge has been acquired, overall improvement is needed to bolster
compliance toward the stakeholder goal. Table 7 lists the validated knowledge influences and
their attribution as a strength or weakness.
Table 7
Validated Knowledge Influences
Knowledge Influence Type Strength
or
Weakness
The Clinical Team needs to know the basis of each
element along with the roles and responsibilities required
for implementation.
Declarative
(Factual)
Weakness
The Clinical Team needs knowledge of the connection
between the bundle elements and the sequential order of
elements.
Declarative
(Conceptual)
Weakness
The Clinical Team needs to understand the link between
protocol algorithms, documentation, and compliance
measurement
Declarative
(Conceptual)
Strength
The Clinical Team needs knowledge of how to implement
the protocol for each element, and the ABCDEF bundle in
sequence.
Procedural Weakness
The Clinical Team needs knowledge of how to perform
multidisciplinary patient rounding and how to use
rounding as a source for care coordination and review of
the ABCDEF bundle for each patient.
Procedural Weakness
The Clinical Team needs to be able to read, understand,
and monitor compliance and patient outcomes reports,
and connect this to action plans that will increase
compliance across roles.
Procedural Weakness
The Clinical Team needs to reflect on their effectiveness
at delivering the bundle using compliance reports.
Metacognitive Strength

84

Motivation Results
If knowledge is needed to perform tasks, then motivation is needed to drive task
engagement (Mayer, 2011). The researcher focused on two motivational influences, known as
utility value and self-efficacy. The assumed influence linked to utility value asserted that the
Clinical Team needed to understand the value of adopting the ABCDEF bundle to be motivated
to adhere to the protocol. For self-efficacy, that assumed influence stated the Clinical Team
needed to believe they could achieve compliance targets, interpreting compliance reports, and
taking action as individuals and the team as a whole. The results of the analysis of motivational
influences are discussed within each influence section starting with utility value and concluding
with self-efficacy.
Utility Value. One confidence interval question and five Likert scale questions were
dedicated to understanding utility value related to the ABCDEF bundle implementation. Figure
10 shows in shades of blue that 83% have a high level of confidence that the ABCDEF bundle
improves patient care and outcomes. Detailed statistics further support these results as shown in
Table 8. The median value at 90 and interquartile Q1 at 71 and Q3 at 100 signify that the
majority of survey participants responded at the higher level of assurance on the confidence
scale. The mode of 100 also identifies that the most occurring response was the highest level of
confidence for this question.

Figure 10

85

Utility Value Motivation Confidence Interval
Table 8
Utility Value Statistics
Q17_6
The ABCDEF Bundle
Improves Patient Care and
Outcomes
Calculation Value
Mean 81.24
Median 90.00
Mode 100.00
Var 456.64
Std Dev 21.37
Min 0.00
Max 100.00
Range 100.00
Q1 71.00
Q2 90.00
Q3 100.00
Q4 100.00
IQR 29.00

1%
2%
1%
1%
5%
6%
8%
14%
21%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
The ABCDEF bundle improves patient care and outcomes
UTILITY VALUE MOTIVATION
CONFIDENCE INTERVALS
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

86

Questions posed for utility value had a positive and negative frame. For instance, two
questions asked respondents to react to whether they felt the ABCDEF bundle implementation
increased or decreased patient outcomes. The results show that these two questions had inverse
responses, validating how survey participants felt regarding patient outcomes. Figure 11 shows
that 88% of respondents had a level of agreement that implementation of the ABCDEF bundle
increased patient outcomes. Conversely, 79% had a level of disagreement in response to feeling
the implementation of the bundle decreased patient outcomes. 68% of survey participants had a
level of disagreement, shown in orange, that the implementation of the bundle did not affect
patient outcomes. 90% of respondents felt the amount of work that was expected to be completed
to implement the bundle was reasonable. 87% had a level of agreement that ABCDEF bundle
compliance improved with the implementation of compliance reports. The results of these survey
questions imply that the Clinical Team felt the ABCDEF bundle was of value to implement.
Figure 11
Utility Value Motivation

87

Self-Efficacy. The theory of self-efficacy relies on the principle that an individual needs
to believe in their ability to achieve their goals (Bandura, 2000; Pajares, 2006). In the case of the
Clinical Team, this theory would translate to both the individual and the team as a whole because
the ABCDEF bundle implementation hinges on the coordinated work of the team to be
compliant. Two survey questions were used to understand self-efficacy for survey participants as
individuals and again as a team. Figure 12 reveals that survey participants felt more confident in
their individual ability to perform the ABCDEF bundle as compared to members of the Clinical
Team. Shown in shades of blue, 88% of respondents answered within the higher range of

22%
23%
4%
5%
21%
41%
40%
11%
13%
48%
24%
25%
6%
15%
21%
7%
7%
17%
17%
7%
4%
3%
40%
35%
2%
2%
2%
22%
16%
2%
I FEEL ABCDEF
BU N D L E
CO M P LI A NCE
IMPROVED WITH
T HE
I M P LEM ENT A T I O N
OF A - F
CO M P LI A NCE
RE P O RT S
I FEEL THE
I M P LEM ENT A T I O N
OF THE BUNDLE
INCREASED PATIENT
OU T C OM E S
I FEEL THE
I M P LEM ENT A T I O N
OF THE BUNDLE
D ECR EA S ED
PATIENT OUTCOMES
I FEEL THE
I M P LEM ENT A T I O N
OF THE BUNDLE
DIDN'T AFFECT
PATIENT OUTCOMES
THE AMOUNT OF
WORK I AM
EXPECTED TO
COMPLETE TO
IMPLEMENT THE
BUNDLE IS
R EA S O NA B LE
UTILITY VALUE MOTIVATION
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

88

confidence levels concerning their individual performance of the ABCDEF bundle on patients,
while 75% responded on the same spectrum for team performance. Table 9 details the statistics
that support these results, showing a lower mean value and variance for the team versus the
individual. Lower variance signifies that more respondents answered closer to the mean value of
83.62 and within interquartile Q1 (75) and Q3 (100) for the individual, compared to the mean
value of 76.07 and interquartile Q1 (61) and Q3 (91.50) for performance of the Clinical Team.
These statistics infer that more respondents had a higher level of assurance in their individual
ability than that of the Clinical Team.
Figure 12
Self-Efficacy Motivation Confidence Intervals

1% 1%
0%
1%
0%
2%
0%
2%
4%
9%
6%
10%
6%
12%
17%
16%
22%
21%
43%
26%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Performing the ABCDEF bundle on patients in my unit
daily
All members of the clinical team are performing the
bundle when indicated that it is appropriate for patient
care
SELF-EFFICACY MOTIVATION
CONFIDENCE INTERVALS
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

89

Table 9
Self-Efficacy Statistics

Q17_1 Q17_9

Performing the
ABCDEF Bundle
on Patients in my
Unit Daily
All Members of the Clinical
Team are Performing the Bundle
when Indicated that it is
Appropriate for Patient Care
Calculation Value Value
Mean 83.62 76.07
Median 90.00 80.00
Mode 100.00 100.00
Var 303.06 430.78
Std Dev 17.41 20.76
Min 0.00 0.00
Max 100.00 100.00
Range 100.00 100.00
Q1 75.00 61.00
Q2 90.00 80.00
Q3 100.00 91.50
Q4 100.00 100.00
IQR 25.00 30.50

Document Review. Evidence showed that compliance and outcome measurement is
essential to sustain implementation of quality care bundles (Bassett et al., 2015; DeMellow &
Kim, 2018; Resar et al., 2012). Therefore, during M3 of the implementation the Clinical Team
was provided patient outcome reports in addition to their ABCDEF bundle compliance
performance. Appendix H exhibits the compliance and outcome reports distributed to each unit
monthly. Appendix H, Figure 28 shows the impact of the ABCDEF bundle implementation to
three distinct patient outcomes. Detailed statistics were also computed to assess the impact of
bundle implementation on patient outcomes to confirm gains in patient outcomes observed
during the study. Each individual element and the whole ABCDEF bundle were associated with
a lower likelihood of death within seven days of hospitalization (p<.0001). Specifically, when
the full ABCDEF bundle implemented was delivered there was an 87% less chance of mortality

90

compared to partial bundle adherence. This gain in patient outcome achieved from whole bundle
implementation versus partial emphasized the importance of practicing the entire ABCDEF
bundle in daily practice.
Individual bundle elements and partial bundle completion also resulted in improved
patient outcomes. For example, partial bundle compliance resulted in a lower risk of persistent
ventilation (p<.005). Execution of element B and E were associated with an increased chance of
discharge to home as opposed to a long-term care facility (p<.0001) and integrating element B in
daily practice was associated with lower risk for delirium. These findings underlined the
significance of implementing the bundle, even if delivered partially.
The compliance and outcome reports were provided to allow the Clinical Team to assess
the impact of incorporating the ABCDEF bundle in daily practice and promote both self-efficacy
and utility value. The researcher hypothesized that the compliance results would garner
confidence when the Clinical Team increased ABCDEF bundle performance, and the outcome
reports would raise value when revealing increased patient outcomes. The researcher extended
analysis of the compliance results for the knowledge influences in Figure 9 to the motivation
influences, establishing bundle compliance performance was an artifact of success in motivation.
Mayer (2011) notes that knowledge is leveraged for task execution, while motivation compels
task engagement. The statistically significant increase in bundle performance over the study
period was used as an indication of the Clinical Team possessing both the knowledge and
motivation to incorporate the ABCDEF bundle in daily practice. Irrespective of falling short of
the stakeholder goal of 95% compliance, the increase in bundle adherence suggest that the
Clinical Team maintained the motivation necessary to execute the ABCDEF bundle.

91

Motivational Influence Summary. Survey results combined with the document review
exhibited the presence of utility value among the Clinical Team regarding the implementation of
the ABCDEF bundle. When asked if the bundle did not affect patient outcomes 68% of
participants responded with a degree of disagreement, indicating that they believed there was an
effect. This result combined with the 88% of participants reporting they felt the ABCDEF bundle
promoted an increase in patient outcomes is evidence that the Clinical Team valued the bundle
implementation. Survey results further revealed a divergence in the level of confidence Clinical
Team members felt about their individual ability versus the performance of the collective.
Clinical Team members were less assured that their colleagues were performing the bundle, as
compared to themselves as individuals. ICU care requires coordinated patient care efforts
(Donovan et al., 2018; Ervin et al., 2018; Manthous & Hollingshead, 2011). Successful
implementation of the ABCDEF bundle requires cross disciplinary patient care coordination
(Bassett et al., 2015; Barnes-Daly, Phillips & Ely, 2017; Barnes-Daly et al., 2018; Boehm et al.,
2016; Boltey et al., 2019; Bounds et al., 2016; Hermes et al., 2018; Kram et al., 2015),
necessitating a high degree of collective efficacy. Table 10 designates self-efficacy as a
weakness given the disparity between the self-efficacy and collective efficacy required to
administer the ABCDEF bundle.
Table 10
Validated Motivation Influences
Motivation Influence Type
Strength
or
Weakness
The clinical team needs to understand the value of adopting
the ABCDEF bundle in daily practice
Motivation Utility
Value
Strength
The clinical team needs to believe they are capable of
achieving compliance targets, interpreting compliance
reports, and taking appropriate action needed to improve
ABCDEF bundle compliance
Motivation Self-
Efficacy
Weakness

92

Organizational Results
The conceptual framework shown in Figure 1 illustrates the intersection of the
knowledge, motivation, and organization influences. In the figure, the knowledge and motivation
influences operate within the organization’s cultural context. As Schein (2017) highlighted,
understanding a culture influence on knowledge and performance is important to driving change.
To that end, the survey elicited responses from participants regarding the cultural model at the
Medical Center and cultural setting. Specifically, the cultural models explored the acceptance of
practice change to incorporate the ABCDEF bundle and culture of trust needed to achieve
interprofessional practice. Cultural settings explored whether the Clinical team felt they received
the appropriate amount of training and education on the bundle, and support from leadership to
achieve their goals.
Cultural Models. Interprofessional practice and care coordination is required to
implement the ABCDEF bundle (Basset et al., 2015, Boltey et al., 2019). The researcher used
compliance performance results to assess practice change as described in the document review
section below. Survey results and the document review were used to evaluate the culture of trust
that was needed to support individual clinicians to operate as a team. Several questions were
used to gauge the feeling of trust amongst the Clinical Team members. Figure 13 exhibits the
level of satisfaction survey participants retained when working with various members of the
Clinical Team. In the four questions, the majority of respondents had a level of agreement (94%;
91%; 84%; 90%) to experiencing good collaboration with a multidisciplinary team member.

93

Figure 13
Organizational Trust
When prompted on whether trust improved with the implementation of the ABCDEF
bundle, survey participants answered favorably. Figure 14 displays a high level of agreement
across three key organizational trust improvement questions. 89% of respondents felt
collaboration improved across disciplines with the implementation of the ABCDEF bundle.
When asked a similar question with an altered frame, 90% of participants felt interprofessional
collaboration increased with the implementation. The same result was true for collaboration
improvement with the implementation of the ABCDEF compliance reports, where 87% of
survey contributors upheld a level of agreement. Results from the survey questions assessing

31%
27%
23%
27%
46%
41%
40%
42%
17%
23%
21%
21%
3%
5%
8%
5%
2%
4%
5%
3%
0%
1%
2%
3%
I EXPERIENCED GOOD
COLLABORATION WITH
NURSES DURING
I M P LEM ENT A T I O N
I EXPERIENCED GOOD
COLLABORATION WITH
PHYSICIANS DURING
I M P LEM ENT A T I O N
I EXPERIENCED GOOD
COLLABORATION WITH
PHYSICAL THERAPY
DU R I N G
I M P LEM ENT A T I O N
I EXPERIENCED GOOD
COLLABORATION WITH
RESPIRATORY THERAPY
DU R I N G
I M P LEM ENT A T I O N
ORGANIZATIONAL TRUST
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

94

trust suggest that implementation of the ABCDEF bundle improves collaboration, coordination,
and trust.
Figure 14
Organizational Trust
Cultural Settings. Schein (2017) describes cultural settings as the mark for daily norms,
rules and policy. Both training and leadership support were cited in the literature as vital aspects
of an organization in order to achieve ABCDEF bundle implementation (Basset et al., 2015;
Boehm et al., 2017, Kram et al., 2015; Leguelinel-Blache et al., 2018; Manici et al., 2018). Ten
survey questions were used to validate the assumed influences of focus for cultural settings.
Survey participants responded with a high level of satisfaction for both training and leadership
support. Figure 15 shows the majority of survey participants reported a level of agreement in
satisfaction with the clinical education and training received for the ABCDEF bundle, with 8%

24%
25%
22%
43%
44%
43%
22%
21%
22%
6%
5%
7%
4%
4%
5%
1%
1%
1%
COLLABORATION IMPROVED
ACROSS DISCIPLINES WITH THE
IMPLEMENTATION OF THE
ABCDEF BUNDLE
I N T E R P R OFE SSI ON AL
COLLABORATION INCREASED
WITH ABCDEF BUNDLE
I M P LEM ENT A T I O N
COLLABORATION IMPROVED
ACROSS DISCIPLINES WITH THE
IMPLEMENTATION OF THE
ABCDEF COMPLIANCE REPORTS
ORGANIZATIONAL TRUST IMPROVEMENT
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

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of respondents responding with some level of disagreement. 86% of participants also replied
some level of agreement when asked if they had enough training to use ABCDEF bundle
compliance reports. Additionally, detailed analysis of the compliance data further revealed a
statistically significant impact of the M1 clinical education intervention on the bundle
compliance as a whole (p< 0.02). Figure 16 shows that 91% of participants had some level of
agreement when asked if the department provided the tools they needed to implement the
ABCDEF bundle. 87% felt they had the support they needed when utilizing the ABCDEF bundle
compliance reports.
Figure 15
Organization Training

22%
18%
49%
44%
19%
23%
4%
9%
2%
3%
2%
2%
I AM SATISFIED WITH THE CLINICAL EDUCATION
AND TRAINING I RECEIVED FOR: - THE ENTIRE
ABCDEF BUNDLE
I FEEL I RECEIVED ENOUGH TRAINING TO USE THE
COMPLIANCE REPORTS TO MANAGE MY UNITS
ABCDEF BUNDLE COMPLIANCE
ORGANIZATION TRAINING
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

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Figure 16
Organization Leadership Support
Document Review. ABCDEF bundle compliance reports obtained during the document
review were used as the main proxy measure to evaluate the assumed influence of a culture of
acceptance to change existing practice to adopt the ABCDEF bundle. An increase in compliance
would represent a willingness to change, and a stagnant or decreased compliance would suggest
a culture of change resistance. The statistically significant increase of adherence to the ABCDEF
bundle demonstrated a willingness of the Clinical Team to adopt new practice, and therefore a
culture that supports adaption to change.
Organization Influence Summary. All survey question results in the organization
influence category showed a strong level of agreement pertaining to the assumed influences
addressing cultural models and settings. The increase in compliance performance found in the
document review and the positive skew toward agreement in the survey results suggest an

22%
20%
44%
44%
25%
23%
6%
9%
2%
3%
1%
1%
MY DEPARTMENT PROVIDED ALL THE TOOLS I
NEEDED TO BE SUCCESSFUL TO PERFORM THIS
BUNDLE IN DAILY PRACTICE
I RECEIVED THE SUPPORT I NEEDED FROM THE
ADMINISTRATION TEAM THROUGHOUT THE
IMPLEMENTATION OF THE ABCDEF COMPLIANCE
RE P O RT
ORGANIZATION LEADERSHIP SUPPORT
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

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alignment between implementation interventions, increased ABCDEF bundle compliance, and
organizational support. Irrespective of this finding, Table 11 designates the cultural models of
practice change and trust as a weakness that needs improvement. The cultural model influences
were evaluated as a weakness due to the gap between actual performance and the organizational
goal of 95% compliance to evidence-based practice, paired with the need for improvement in
collective efficacy identified in the motivation section. Table 11 reviews the validated
organization influences and their classification as a strength or weakness.
Table 11
Validated Organization Influences
Organization Influence Type Strength
or
Weakness
The organization needs to facilitate a general acceptance
and willingness among the Clinical Team to change existing
practice to adopt the ABCDEF bundle.
Organization
Cultural Model
Weakness
The organization needs a culture of trust across the
disciplines within the Clinical Team in order to achieve the
interprofessional practice necessary for adherence to the
ABCDEF bundle daily.
Organization
Cultural Model
Weakness
The organization needs to give the Clinical Team time to
receive the appropriate amount of training and education on
each bundle element, and the bundle’s application as a
whole.
Organization
Cultural Setting
Strength
The Clinical Team needs organization leadership to support
the integration of the ABCDEF bundle into practice.
Organization
Cultural Setting
Strength
Summary of Findings
The results of the survey and document review were used to validate the assumed
influences and assess the ability of the stakeholders to reach their goal of achieving greater than
or equal to 95% compliance during the implementation of the novel patient care approach. The
implementation of the bundle at the Medical Center was designed to incorporate the assumed
influences outlined in Table 5. According to the document review, the Clinical Team at the
Medical Center failed to reach the 95% goal during the study time period. Figure 9 shows that

98

the highest level of compliance reached by all four ICUs was 33%. Despite not reaching the 95%
goal, Figure 9 also confirms that the Clinical Team achieved a statistically significant increase in
their adherence to the bundle and exceeded the national benchmark for ABCDEF bundle
compliance by 17% during their implementation. Therefore, the results of the study validated
both the assumed KMO influences, as well as the implementation barriers that were identified in
the literature.
By IHI standards, an implementation barrier includes that the ABCDEF bundle exceeds
the six bundle design recommendations focused on simplicity and minimal steps (Resar et al.,
2012). The IHI specifically states that more than five bundle elements may be too complicated
and prevent a reliable implementation. The ABCDEF bundle contains six elements that rely on
care coordination across disciplines along multiple processes of care. Despite the complexity of
the ABCDEF bundle, the Clinical Team was able to increase the bundle compliance as a whole,
as well as the adherence to the processes of care for each individual element shown in Appendix
G. The increase in compliance implies that the assumed influences incorporated in the
implementation approach are valid influences to consider when approaching ABCDEF bundle
implementation. The Clinical Team’s responses to the survey further substantiate the validation
of the assumed influences. The following section discusses the researcher’s findings during the
study with emerging themes classified by the original research questions set forth at the onset of
the study.
Research Questions 1: What is the ICU Clinical Team’s knowledge and motivation related to
implementing the ABCDEF bundle on greater than 95% of ICU patient cases within the
Critical Care Center?

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Since the inception of the ABCDEF bundle, evidence has demonstrated clear gains in
positive patient outcomes. The evidence has also highlighted the difficulty in attaining adherence
to the bundle due to the complex nature of the process of care of each element. The Clinical
Team needs both the knowledge of the ABCDEF bundle, combined with the motivation to
sustain compliance goals. Analysis of both the survey results and ABCDEF bundle compliance
performance identified three themes as key knowledge and motivation influences, including roles
and responsibilities, value, and compliance monitoring. The identified weaknesses that the
Clinical Team need to address to bridge the gap between their goal and performance coincides
with the central themes outlined below.
Roles and Responsibilities. The complexity of the ABCDEF bundle and the multiple
processes of care necessary to complete the bundle require distinct knowledge of when and how
to both act and communicate to other members of the Clinical Team (Boltey et al., 2019). While
94% of survey respondents had a level of agreement when asked if they understood their roles
and responsibilities, only 27% strongly agreed. The question was also posed to the individual
themselves, seeking their perspective of their own knowledge. Participants may have believed to
understand roles and responsibilities but in practice may not have performed and communicated
their actions as delineated by the ABCDEF bundle roles and responsibilities. Knowledge was
more concretely measured using the compliance results in the document review. The researcher
observed an increase in compliance results following the interventions but a significant gap to
the goal remained. Additionally, an increase in compliance of a higher degree compared to the
bundle as a whole was observed across each process of care of the individual elements. The gap
to goal and the higher degree of compliance in individual elements compared to the whole
bundle suggest a lack of understanding in roles and responsibilities regarding sequencing and

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coordinating the process of care to meet the whole bundle requirements. Furthermore, survey
respondents revealed a higher level of assurance in their individual ability than that of the team
performing bundle elements, signifying a lack of confidence in the team’s knowledge and
motivation pertaining to roles and responsibilities.
Value. Value in healthcare is defined as the quality of patient care over cost (Porter,
2010). Multiple survey question results supported that the Clinical Team felt the ABCDEF
bundle improved patient outcomes, but in a question inquiring whether respondents felt
implementation did not affect patient outcomes, 32% responded with a level of agreement, with
5% strongly agreeing. Moreover, the utility value questions showed a majority of mid-level
agreement (< 40%), with lower levels of strongly agree responses. Implementation of the
ABCDEF bundle in the Medical Center resulted in improved patient outcomes, particularly in
whole bundle implementation versus partial. The value of adhering to the whole bundle daily
became clear in the improved mortality, lower chance of needing a ventilator for an extended
period, and increased chance of discharge to home. Despite the improvement in patient outcomes
with partial bundle compliance, the study found the need for an emphasis on the value of
adopting the ABCDEF bundle as whole approach rather than individual processes of care.
Deliberately presenting the outcome results to the Clinical Team in daily practice to demonstrate
the bundles value to patients may be needed to increase the perceived value of ABCDEF bundle
adoption.
Compliance Monitoring. Compliance measurement is essential to implementing
sustainable quality care bundles (Bassett et al., 2015; DeMellow & Kim, 2018; Resar et al.,
2012). Survey results supported the importance of data as a prominent article needed for
ABCDEF bundle implementation. Questions posed to participants elicited responses on

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interpretation of data and reports separately from their feelings on the ABCDEF bundle
compliance reports. Responses to data and reports denote a high level of agreement on
individuals’ feelings of skills and ability to interpret and manage data and reports. Survey results
also suggested the availability of compliance reports helped increase individual’s ability to
interpret data. Conversely, the researcher noted 28% of participants responded with a low level
of assuredness in monitoring their unit’s compliance. The Clinical Team felt they had the skills
to read and interpret data reports but did not feel confidence in managing their unit’s ABCDEF
bundle compliance, signifying the need for improvement in the process of creating and providing
ABCDEF compliance reports. The knowledge and motivation themes of roles and
responsibilities, value, and compliance monitoring are areas for improvement addressed in the
recommendations listed in chapter 5.
Research Questions 2: What is the interaction between the Critical Care Center’s culture and
context and the ICU Clinical Team’s knowledge and motivation related to implementing the
ABCDEF bundle on greater than 95% of ICU patient cases within the Critical Care Center?
Evidence states that the implementation of the ABCDEF bundle hinges upon the
ability for the Clinical Team to coordinate care among the various clinical disciplines
(Barnes-Daly et al., 2017; Barnes-Daly et al., 2018; Bassett et al., 2015; Boehm et al., 2016;
Boltey et al.,, 2019; Bounds et al., 2016; Hermes et al., 2018; Kram et al., 2015). A shift from
the historic hierarchical structure of patient care to a team-based interprofessional approach has
shown improvement in the healthcare setting (Donovan et al., 2018; Ervin et al., 2018; Manthous
& Hollingshead, 2011). Moreover, addressing culture and the presence of collaboration across
clinical disciplines has been cited as critical to the adoption of the ABCDEF bundle (Basset et
al., 2015; Marra et al., 2017). The study dedicated several survey questions to evaluating the

102

cultural model and cultural settings known as organizational influences. The organizational
influence questions were used to answer the research question assessing the interaction between
the Critical Care Center’s culture and context related to implementing the ABCDEF bundle on
greater than 95% of ICU patients. This section highlights themes that emerged during the study
regarding culture and context that are needed to bolster compliance and successfully reach the
stakeholder goal.
Data Availability. The importance of data and compliance reports that were outlined in
the knowledge and motivation influences indicate the need for an organization cultural setting
focused on availability of data. Evidence generated from the study confirmed the assertion of
research articles stating data and ABCDEF bundle compliance reports are required to assess
bundle performance and course correct in real-time (Barnes-Daly et al., 2018; Bassett et al.,
2015; Proctor et al., 2015; Pun et al., 2019). Organizations must provide data assets during the
ABCDEF bundle implementation for clinicians to assess their performance and improve in real-
time. Compliance reports were provided to the clinicians on a weekly basis following the M3
data literacy education. Technology limitations of the EMR at the Medical Center prevented the
generation of the compliance reports at a faster cadence.
Practice Change. The statistically significant increase ABCDEF bundle compliance
demonstrated a willingness of the Clinical Team to adopt new practice. However, the gap
between performance and goal may be evidence of change resistance on the part of individuals.
Establishing a cultural model that embraces a shared learning approach may yield the action
needed to successfully reach the stakeholder goal (Schein, 2017).
Teamwork. Trust across clinical disciplines is needed to foster healthcare change
(Berwick, 2003). Survey results evaluating trust and collaboration suggested that the

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implementation of the ABCDEF bundle improved teamwork. However, the document review
revealed that individual processes of care for each element of the bundle had higher compliance
results than the whole bundle compliance that requires coordination across the disciplines. A
focus to improve and sustain effective teamwork is required for any evidence-based practice that
requires multidisciplinary collaboration in the healthcare setting.
Organizational Support. Kram et al. (2015) noted approval, support, and dedicated
resources were essential to establish an environment that supports ABCDEF bundle adoption.
Survey results established a high level of satisfaction for both training and leadership support
from the Medical Center during the ABCDEF bundle implementation. The increase in bundle
compliance paired with the positive responses from survey participants suggest organizational
support is needed to adopt evidence-based protocols into daily practice.
Summary of Validated Influences
The strengths and weaknesses outlined in Table 12 were the subject of evidenced based
recommendations in chapter 5. This concluding chapter will address the third research question.
Research question three inquires as to what are the recommended knowledge, motivation, and
organizational solutions?
Table 12
Summary of Validated Influences

Influence Type Strength or
Weakness
The Clinical Team needs to know the basis of each element
along with the roles and responsibilities required for
implementation.
Knowledge
Declarative
(Factual)
Weakness
The Clinical Team needs knowledge of the connection
between the bundle elements and the sequential order of
elements.
Knowledge
Declarative
(Conceptual)
Weakness
The Clinical Team needs to understand the link between
protocol algorithms, documentation, and compliance
measurement
Knowledge
Declarative
(Conceptual)
Strength

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The Clinical Team needs knowledge of how to implement
the protocol for each element, and the ABCDEF bundle in
sequence.
Knowledge
Procedural
Weakness
The Clinical Team needs knowledge of how to perform
multidisciplinary patient rounding and how to use rounding
as a source for care coordination and review of the
ABCDEF bundle for each patient.
Knowledge
Procedural
Weakness
The Clinical Team needs to be able to read, understand, and
monitor compliance and patient outcomes reports, and
connect this to action plans that will increase compliance
across roles.
Knowledge
Procedural
Weakness
The Clinical Team needs to reflect on their effectiveness at
delivering the bundle using compliance reports.
Knowledge
Metacognitive
Strength
The clinical team needs to understand the value of adopting
the ABCDEF bundle in daily practice
Motivation
Utility Value
Strength
The clinical team needs to believe they are capable of:
achieving compliance targets, interpreting compliance
reports, and taking appropriate action needed to improve
ABCDEF bundle compliance
Motivation
Self-Efficacy
Weakness
The organization needs to facilitate a general acceptance
and willingness among the Clinical Team to change existing
practice to adopt the ABCDEF bundle.
Organization
Cultural
Model
Weakness
The organization needs a culture of trust across the
disciplines within the Clinical Team in order to achieve the
interprofessional practice necessary for adherence to the
ABCDEF bundle daily.
Organization
Cultural
Model
Weakness
The organization needs to give the Clinical Team time to
receive the appropriate amount of training and education on
each bundle element, and the bundle’s application as a
whole.
Organization
Cultural
Setting
Strength
The Clinical Team needs organization leadership to support
the integration of the ABCDEF bundle into practice.
Organization
Cultural
Setting
Strength

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Chapter Five: Recommendations
The results and findings section of this study highlighted the strengths and weaknesses of
the Medical Center uncovered when implementing the ABCDEF bundle in four ICU’s. Room for
improvement was noted in all influences, and the need to improve both strengths and weaknesses
to reach organizational goals is suggested by the researcher. This final chapter outlines evidence-
based recommendations to address the gaps in knowledge, motivation, and organizational
influences found by engaging staff in a survey and monitoring the ABCDEF bundle compliance
over a year period. The chapter begins with solutions categorized by the knowledge, motivation,
and organization influences and continues with the integration of the New World Kirkpatrick
Model (Kirkpatrick & Kirkpatrick, 2016) as a framework to evaluate results. Based on the
evidence gathered in this study, the Medical Center should alter their ABCDEF bundle
implementation approach to incorporate the recommendations outlined in this chapter to improve
ABCDEF bundle compliance performance.
Recommendations for Practice to Address KMO Influences
The Clinical Team’s compliance performance results demonstrated acquisition of
knowledge on how to implement the ABCDEF bundle. However, room for improvement was
noted in the Clinical Team’s approach to whole ABCDEF bundle compliance. Individual
processes of care within each element of the ABCDEF bundle showed compliance above 60%,
whereas whole bundle compliance achieved a maximum number of 33% over the year study
period. A complete list of validated knowledge influences and their classification as a strength or
weakness is presented in Table 13. Table 13 includes context specific recommendations based on
theoretical principles to sustain the Clinical Team’s strengths and fortify their weaknesses.
Table 13
Summary of Knowledge Influences and Recommendations

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Assumed Knowledge
Influence: Cause, Need,
or Asset*

Strength
(S) or
Weakness
(W)
Principle and Citation
Context-Specific
Recommendation
The Clinical Team needs
to know the basis of each
element along with the
roles and responsibilities
required for
implementation. (D)
W How individuals
organize
knowledge influences
how they
learn and apply what
they know
(Schraw &
McCrudden, 2006).
Provide the Clinical Team
with a job aid that
organizes roles and
responsibilities for
implementation and
emphasizes points of care
coordination.
The Clinical Team needs
knowledge of the
connection between the
bundle elements and the
sequential order of
elements. (D)
W To develop mastery,
individuals
must acquire
component skills,
practice integrating
them, and
know when to apply
what they
have learned (Schraw
&
McCrudden, 2006).

Effective observational
learning is achieved
by first organizing and
rehearsing modeled
behaviors, then
enacting them overtly
(Mayer, 2011).

Provide timely
feedback that links use
of learning strategies
with improved
performance (Shute,
2008).
Provide the Clinical Team
with opportunities for
additional training
including observation and
simulation of
implementation of the
bundle in sequential order.

Provide the Clinical Team
with a job aid that
organizes the bundle
elements in sequential
order and indicates the
connection between the
flow of elements.

The Clinical Team needs
to understand the link
between protocol
algorithms,
documentation, and
compliance measurement
(D)
S How individuals
organize
knowledge influences
how they
learn and apply what
they know
(Schraw &
McCrudden, 2006).

Provide the Clinical Team
with a job aid that links
protocol algorithms,
documentation and
compliance measurement.

107

The Clinical Team needs
knowledge of how to
implement the protocol
for each element, and the
ABCDEF bundle in
sequence. (P)
W Help learners acquire
new behaviors
through demonstration
and modeling
(Denler et al., 2009).

Model effective
strategy use, including
“how” and “when” to
use particular
strategies
(Schraw &
McCrudden, 2006)
Provide a job aid that
demonstrates the steps and
give the Clinical Team the
opportunity to observe then
practice the protocol with
feedback.
The Clinical Team needs
knowledge of how to
perform multidisciplinary
patient rounding and how
to use rounding as a
source for care
coordination and review
of the ABCDEF bundle
for each patient. (P)
W Provide guidance,
modeling, coaching,
and other scaffolding
during performance
(Mayer, 2011)

Provide training to team
leaders to guide and coach
performance during patient
rounding toward care
coordination.

Provide the Clinical Team
a job aid that demonstrates
a checklist of steps to share
information needed for care
coordination during
rounding.

The Clinical Team needs
to be able to read,
understand, and monitor
compliance and patient
outcomes reports, and
connect this to action
plans that will increase
compliance across roles.
(P)
W How individuals
organize
knowledge influences
how they
learn and apply what
they know
(Schraw &
McCrudden, 2006).

The use of
metacognitive
strategies facilitate
learning
(Baker, 2006; Dembo
&
Eaton, 2000).

Provide training
opportunities to teach
learners strategies to
manage their
Provide the Clinical Team
with a job aid that outlines
how to manage compliance
and outcome reports and
connects them to action.

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motivation, time,
learning strategies,
control their physical
and social
environment, and
monitor their
performance (Dembo
&
Eaton, 2000)

The Clinical Team needs
to reflect on their
effectiveness at delivering
the bundle using
compliance reports. (M)
S Provide the use of
metacognitive
strategies to facilitate
learning
(Baker, 2006).

Provide opportunities
for learners to check
their progress and
adjust their learning
strategies as needed
(Denler et al., 2009)

Provide opportunities to
reflect on performance
individually and as a
Clinical Team including
feedback, team debriefs,
ongoing discussions with
team mentors and leaders,
and during review of
compliance performance
reports.

Knowledge Recommendations
Declarative Knowledge Solutions
The results and findings showed that knowledge was gained by the Clinical Team,
validating the assumed knowledge influences. However, opportunities to increase compliance
were found in relation to all knowledge influences. For example, in declarative knowledge
individual members of the Clinical Team need to better understand their roles and
responsibilities and sequencing of bundle elements as it relates to care coordination across
disciplines. To increase the Clinical Team’s gains in declarative knowledge, information
processing and social cognitive theories can be applied as a foundation for recommendations.
Schraw and McCrudden (2006) noted that an individual's organization of knowledge influences
how they learn and apply what they know. The authors also suggested that to develop mastery,
individuals must acquire component skills, practice integrating them, and know when to apply

109

what they have learned. Mayer (2011) confirmed the need for practice through the inclusion of
effective observational learning that is achieved by first organizing and rehearsing modeled
behaviors, then enacting them explicitly. In complement, Shute (2008) suggested delivering
timely feedback that links the use of learning strategies with improved performance as a key
component to promote knowledge retention. The principles from these theories imply that the
Clinical Team would benefit from training and job aids. The researcher recommends providing
the Clinical Team with opportunities for additional training including observation of
implementation of the bundle in sequential order that is combined with feedback on how to
improve performance. Additionally, the researcher recommends providing the Clinical Team
with job aids, such as an infographic, that organizes roles, responsibilities, and bundle element
sequential ordering for implementation, and emphasizes points of care coordination.
A key principle for adopting the ABCDEF bundle in practice is the knowledge of the
interrelationship of elements and their sequential delivery (Bassett et al., 2015). Moreover,
consistent coordination and action are essential to achieving quality bundle compliance targets
(Donovan et al., 2018; Resar et al., 2012). To drive motivation and alignment toward a
performance goal, individuals should know what is expected of them and when they need to
perform a task (Clark, 2003). Wilford and Doyle (2006) promoted the use of simulation training
as a means to combine clinical skills transfer with teamwork, communication, care coordination,
feedback, and reflection. Kneebone et al. (2006) supported the simulation approach stating that
traditional methods of clinical education need to be augmented with simulation training to
effectively transfer skills. Therefore, the evidence suggests that the Clinical Team would benefit
from additional training with a simulation or role play approach to bridge the knowledge gaps
identified in the study.

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In addition to training, job aids may assist in providing the delineation of roles and
responsibilities in training and at the bedside as a self-help tool. Intelligent job aids in the
medical field have existed to improve performance for many years (Richards, 1988). Kumar et
al. (2011) noted concept maps as visual job aids can facilitate the connection between reports and
taking actions. Thus, as shown by the literature, the Clinical Team would benefit from job aids.
Procedural Knowledge Solutions
Similar to declarative knowledge, the study identified room for improvement in relation
to the individual Clinical Team members' understanding of how to execute the ABCDEF bundle
as a multiprofessional team. Recommendations rooted in social cognitive and information
processing theories have been identified by the researcher to improve strengths and weaknesses
in the procedural knowledge influences. Schraw and McCrudden (2006) suggested including
“how” and “when” to use particular strategy to model effective strategy use. Demonstration and
modeling can help individuals attain new behaviors (Denler et al., 2009). Mayer (2011) added
the need to provide guidance, modeling, coaching, and other structures during performance.
Additionally, the use of metacognitive strategies facilitates learning (Baker, 2006; Dembo &
Eaton, 2000). Dembo and Eaton (2000) recommended providing training opportunities that teach
managing learner motivation, time, learning strategies, controlling the environment, and
monitoring performance. These theories suggest that the Clinical Team would improve their
knowledge with training that incorporates observation and feedback and distribution of
additional job aids. The researcher recommends the following to aid in procedural knowledge
learning (a) provide job aids that demonstrate the bundle steps combined with the opportunity to
observe and practice the protocol with feedback; (b) provide job aids with a checklist of steps to
communicate information needed for care coordination during rounding; (c) provide training to

111

team leaders to guide and coach performance during patient rounding toward care coordination;
(d) provide an infographic or job aid that outlines how to manage compliance and outcome
reports and connect them to action; (e) provide opportunities to reflect on performance
individually and as a Clinical Team including feedback, team debriefs, ongoing discussions with
team mentors and leaders, and during review of compliance performance reports.
Research shows that to reduce errors and reduce complexity, checklists should be
developed to support complex processes of care (Hales & Pronovost, 2006; Laurance, 2009).
Checklists operate as job aids in the clinical space. Providing checklists during care significantly
improves patient care and safety (Hales & Pronovost, 2006). The evidence suggests that
providing job aids to support the ABCDEF bundle implementation would serve to increase
procedural knowledge in training and at the point of care.
With respect to training, Cannon-Bowers and Salas (1998) found that trained leaders
produced better team performance than untrained leaders. Furthermore, the authors noted that
team self-correction, a process where the team diagnoses problems and develops effective
solutions, is best guided by a team leader. The theory suggests training team leaders can
positively influence team performance. Therefore, training team leaders on guiding and coaching
performance would benefit the Clinical Team.
Metacognitive Knowledge Solutions
The results and findings highlighted that the metacognitive knowledge associated with
the use of compliance reports was strengthened by the data literacy training implemented during
the study. However, Chapter Four found room for improvement in the confidence level of the
team to specifically read and interpret ABCDEF bundle compliance reports. The use of social
cognitive and information processing theories have been identified by the researcher as strategies

112

to advance the metacognitive knowledge influence. Baker (2006) affirms that the use of
metacognitive strategies facilitates learning. The recommendation for the Clinical Team follows
the Denler et al. (2009) approach to provide opportunities for learners to check their progress and
adjust their learning strategies as needed. To support this recommendation, the Clinical Team
needs consistent access to their compliance performance.
Performance measurement to reflect on practice, provide feedback, and course correct is
essential to sustaining quality care bundles (Bassett et al., 2015; DeMellow & Kim, 2018; Resar
et al., 2012). Furthermore, access to actionable data can close knowledge gaps and promote
collaboration across the multidisciplinary team (Collinsworth et al., 2014; Ervin et al., 2018; Pun
et al., 2019). Thus, the Clinical Team needs access to the ABCDEF bundle compliance in order
to reflect and improve performance.
Motivation Recommendations
The Clinical Team’s motivation to adhere to the ABCDEF bundle was evident in the
compliance results. Although, opportunities for improvement were observed in the gap between
the stakeholder goal and performance. A complete list of validated motivation influences and
their categorization as a strength or weakness is presented in Table 14. Table 14 includes context
specific recommendations based on theoretical principles to maintain the Clinical Team’s
strengths and reinforce their weaknesses.
Table 14
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence

Strength
(S) or
Weakness
(W)
Principle and Citation
Context-Specific
Recommendation
The Clinical Team
needs to believe they
are capable of
achieving compliance
W High self-efficacy can
positively influence
motivation (Pajares, 2006).

Provide education and
team training on the
bundle to improve
collective efficacy and

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targets, interpreting
compliance reports,
and taking appropriate
action needed to
improve ABCDEF
bundle compliance
(Self-Efficacy)
Feedback as well as actual
success on challenging
tasks positively influences
people’s perceptions of
competence (Borgogni et
al., 2011).

Social interaction,
cooperative learning, and
cognitive apprenticeships
(such as reciprocal
teaching) facilitate
construction of new
knowledge (Scott &
Palincsar, 2006).

the team’s belief in the
ability to improve
ABCDEF bundle
compliance.

Provide performance
feedback to individuals
and teams during
huddles, patient
rounding, and team
meetings.

Model and simulate
multidisciplinary
communication and
practice during bundle
training and provide
feedback during
implementation.
The Clinical Team
needs to understand the
value of adopting the
ABCDEF bundle in
daily practice (Utility
Value)
S The more a person values a
task and the more they
think they are likely to
succeed at it, the greater
their motivation to do it
(Wigfield & Eccles 2000)

Effective change begins by
addressing motivation
influencers; it ensures the
group knows why it needs
to change. It then addresses
organizational barriers and
then knowledge and skills
need (Clark and Estes,
2008).

Provide the Clinical
Team with information
from the literature on
improved patient
outcomes from ABCDEF
bundle use along with
their own unit’s patient
outcome results to
demonstrate the impact
of the bundle on patient
care.
Self-Efficacy
The results and findings revealed a discrepancy between self- and collective- efficacy
among the Clinical Team, exposing the feeling of more confidence in the individual than in the
team. Confidence in both the individual and the team is needed for successful ABCDEF bundle
implementation given the care coordination required across the multidisciplinary team. Both

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individualistic and collective forms of efficacy can coexist in harmony (Bandura, 2000). Multiple
theories, including expectancy value, self-efficacy, sociocultural, and collective efficacy theories
were drawn upon to pose recommendations to sustain self-efficacy and increase collective
efficacy. Pajares (2006) found that high self-efficacy could positively influence motivation.
Bandura (2000) also observed that positive perceptions of collective agency foster increased
motivation, resiliency, and effectiveness. Cannon-Bowers and Salas (1998) supported this when
they found that teamwork skills training had a positive effect on team performance. Scott and
Palincsar (2006) suggested social interaction, cooperative learning, and reciprocal teaching can
facilitate the construction of new knowledge in teams. Paries et al. (2000) advised that training
needed to include a collective focus as training individuals was not enough to promote team
effectiveness. Based on the principles of these theories, the researcher recommends providing
education and team training on the bundle that consists of modeling and simulation with
feedback to improve collective efficacy and the team’s belief in the ability to improve ABCDEF
bundle compliance. Borgogni et al. (2011) found that feedback as well as actual success on
challenging tasks positively influences people’s perceptions of competence. Therefore, the
training and education should incorporate feedback on performance to bolster individuals and
teams perception of competence. Feedback should be incorporated into daily routine by
providing performance feedback to individuals and teams during huddles, patient rounding, and
team meetings.
Boltey et al. (2019) emphasize the importance of teamwork in implementing the
ABCDEF bundle. The author’s found that a shared mental model assisted in the coordination of
patient care. Despite its known benefits, effective teamwork is not present in clinical curriculum
(Ervin et al., 2018; Manthous & Hollingshead, 2011). In a narrative review identifying 187

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articles and evaluating 27 papers against the Kirkpatrick four step model of evaluation, Low et
al. (2018) found that “team training in the ICU is well received by staff, facilitates clinical
learning, and can positively alter staff behaviors” (p. 288).
In order to effectively train teams to improve performance, Paris et al. (2000) assert that
team training should be focused on more than team building, but also presents tools and methods
that include: (a) required competencies; (b) team task analysis; (c) task simulation and exercises;
(d) performance measurement and feedback. The authors elaborate on feedback, stating that
feedback from team leaders is a key tool to developing the team and should be given at a high
frequency from the team leader and the team members themselves. Clark (2003) supports the
inclusion of feedback, suggesting that to increase motivation, feedback should begin with
accomplishments toward the goal, followed by a discussion on ways to close performance
gaps. The author claims that feedback focused on closing the gap between performance and
goals, as opposed to negative feedback that focuses on mistakes is more effective in increasing
individuals’ motivation and performance. Tuckman (2009) also states that immediate feedback
paired with reinforcement is needed to encourage motivation. Moreover, Clark and Estes (2008)
found that candid and ongoing communication regarding processes and plans can bolster
organizational performance. Kaye et al. (2014) emphasize the importance of feedback in the
clinical setting, asserting that effective feedback is an essential component of clinical practice.
Survey results highlighted self-efficacy as a strength for individual members of the Clinical
Team, and collective efficacy as a weakness. Both self- and collective- efficacy are needed due
to the collaboration and teamwork required for effective ABCDEF bundle implementation. The
theoretical evidence supports team training combined with the integration of ongoing feedback

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as a means to maintain self-efficacy and increase the collective efficacy needed to bolster
ABCDEF bundle performance.
Utility Value
Survey results confirmed that the Clinical Team felt implementation of the ABCDEF
bundle improved patient outcomes. This influence aligned with the expectancy value theory and
was an identified strength of the Clinical Team in the study’s results and findings. Expectancy
value theory asserts that the more a person values a task and the more they think they are likely
to succeed at it, the greater their motivation to do it (Wigfield & Eccles 2000). Clark and Estes
(2008) also emphasized that effective change begins by addressing motivation influencers
targeting the reason for change, then addressing organizational barriers followed by knowledge
and skills needs. To fortify this strength, the researcher recommends to provide the Clinical
Team with information from the literature on improved patient outcomes from ABCDEF bundle
use, along with their own units patient outcome results to demonstrate the impact of the bundle
on patient care.
Hermes et al. (2018) suggest that increasing access and awareness of ABCDEF bundle
protocols and performance could improve ICU care. In a study focused on work motivation
among healthcare professionals, Kjellström et al. (2017) found that when organizational goals
are in line with the individual health professional goals work motivation exists. Both authors'
studies suggest providing unit specific information would build awareness on the importance of
the bundle and demonstrate the organization’s oversight and commitment to ABCDEF bundle
implementation.

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Organization Recommendations
The survey results from the study exhibited strong organizational support for the
implementation of the ABCDEF bundle. The cultural settings identified as assumed organization
influences were identified as strengths during the implementation. However, the cultural model
of siloed based care, as opposed to interprofessional practice of the Medical Center and greater
healthcare industry at large, were identified as a weakness. A complete list of validated
organizational influences and their cataloging as a strength or weakness is presented in Table 15.
Table 15 includes context specific recommendations based on theoretical principles to improve
the Clinical Team’s ABCDEF bundle performance.
Table 15
Summary of Organization Influences and Recommendations
Assumed Organization
Influence

Strength
(S) or
Weakness
(W)
Principle and Citation
Context-Specific
Recommendation
The organization needs to
facilitate a general
acceptance and
willingness among the
Clinical Team to change
existing practice to adopt
the ABCDEF bundle.
(Cultural Model)
W Different types of
benchmarking contribute
data to improve
organizational
performance (Bogue &
Hall, 2003).
A strong organizational
culture controls
organizational behavior
and can block an
organization from
making necessary
changes for adapting to a
changing environment
(Schein, 2004).
Provide external and
internal benchmarks to
evaluate organizational
performance in ABCDEF
bundle implementation

Provide incentives that
align with organizational
goals that target the
implementation of the
ABCDEF bundle.

Include education and
training focused on
breaking cultural silos
and hierarchical clinical
practice in the ABCDEF
bundle training program.

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The organization needs a
culture of trust across the
disciplines within the
Clinical Team in order to
achieve the
interprofessional practice
necessary for adherence
to the ABCDEF bundle
daily. (Cultural Model)
W Organizational
effectiveness increases
when leaders are
trustworthy and, in turn,
trust their team. The
most visible
demonstration of trust by
a leader is accountable
autonomy (Colquitt et
al., 2007; Serva et al.,
2005)
Organizational
performance increases
when individuals
communicate constantly
and candidly to others
about plans and
processes (Clark &
Estes, 2008)
Organizational culture is
created through shared
experience, shared
learning and stability of
membership. It is
something that has been
learned. It cannot be
imposed (Schein, 2004).
Provide team leader
training to Clinical Team
leads with an emphasis
on communication and
appropriate feedback
delivery.

Provide a process for
multidisciplinary debriefs
and feedback on
ABCDEF bundle
performance.

Provide a shared learning
experience for care
coordination during
ABCDEF bundle training
and education to foster a
culture of teamwork and
collaboration among the
Clinical Team.
The organization needs to
give the Clinical Team
time to receive the
appropriate amount of
training and education on
each bundle element, and
the bundle’s application
as a whole. (Cultural
Setting)
S Effective change efforts
ensure that
everyone has the
resources (equipment,
personnel, time, etc)
needed to do their job,
and that if there are
resource shortages, then
resources are aligned
with organizational
priorities (Clark and
Estes, 2008).

Provide the resources
needed (training time,
job aids, feedback
mechanisms) to allow the
Clinical Team time to
receive knowledge on the
bundle.
The Clinical Team needs
organization leadership to
support the integration of
the ABCDEF bundle into
S Effective organizations
ensure that
organizational messages,
rewards, policies, and
procedures that govern
Incorporate ABCDEF
bundle into
organizational goals and
incentive plans.

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practice. (Cultural
Setting)
the work of the
organization are aligned
with or are supportive of
organizational goals and
values (Clark and Estes,
2008).

Design of incentive
structure and use of
incentives are more
important than the types
of incentives used
(Elmore, 2002).

Cultural Models
This study found that the culture of trust, collaboration, and teamwork needed to
effectively achieve ABCDEF bundle adherence was a key weakness of the Clinical Team during
implementation. To close the organization influence gap in this avenue, accountability,
leadership, and organizational change principles can be applied. Increasing individual and team
accountability is important to shifting practice to adopt the ABCDEF bundle. To increase
accountability, goals should be set and aligned with incentives supporting ABCDEF bundle
implementation. Goals and benchmarks are essential to evaluating progress and driving
organizational performance (Bogue & Hall, 2003).
Leadership and organizational change principles place emphasis on a leader’s role and
influence over team behavior. Cannon-Bowers and Salas (1998) stated the team dynamic was
impacted by the behavior of their leader. Denning (2005) echoed this finding citing
communication as an essential skill for effective leaders to facilitate change and enhance
organizational capacity. Clark and Estes (2008) also maintain that organizational performance
increases when individuals communicate constantly and candidly to others about plans and

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processes. In the healthcare context, the Institute of Medicine (IOM) (2004) concluded that
transformational leadership is crucial for change initiatives focused on improving the patient care
environment. The IOM defined transformational leadership as leaders that engage their followers
in the pursuit of common goals. This would suggest that the Clinical Team would benefit from
team leaders with strong communication skills to build trust and foster the collaboration needed
for ABCDEF bundle adherence. Thus, it is recommended that team leader training is provided to
the Clinical Team leads with an emphasis on communication and appropriate feedback delivery.
Consistent with Clark and Estes, Schein (2004) suggests a strong organizational culture
controls organizational behavior and can block an organization from making necessary changes
for adapting to a changing environment. The author links organizational behavior to collective
experiences by stating organizational culture is created through shared experience, shared
learning, and stability of membership. The author states that organizational culture is learned and
not imposed. This evidence suggests that including a focus on breaking cultural silos and
hierarchical clinical practice in education and training would benefit the Clinical Team in their
pursuit of their stakeholder goal. The education should consist of a shared learning experience
for training and education with modeling, practice, and feedback for ABCDEF bundle
implementation and cross disciplinary communication. Following education and training a
process to exercise ongoing communication and feedback should be provided by way of
multidisciplinary debriefs and feedback on ABCDEF bundle performance.
Historically, the healthcare culture has supported hierarchical siloed practice within each
clinical discipline (Alexanian et al., 2015; Manthous & Hollingshead, 2011). Shifting care
delivery approaches from siloed care to team-based interprofessional care is known to improve
outcomes in the ICU (Donovan et al., 2018; Ervin et al., 2018; Manthous & Hollingshead, 2011).

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Research evidence has shown that building effective collaboration aids in translating evidence-
based care into practice and fostering a continuous improvement culture (Alexanian et al., 2015;
Manthous & Hollinghead, 2011). However, adopting team-based care approaches remains a
challenge in healthcare (Ervin et al., 2018; Valentine et al., 2015). Building effective teamwork
skills is not currently integrated in clinical curriculum (Ervin et al., 2018; Manthous &
Hollingshead, 2011). Alexanian et al. (2015) explored the barriers to effective teamwork and
communication, finding embedded hierarchies, medical dominance, and professional culture as
key blockers to the success of medical teams. Marra et al. (2017) emphasize that the ABCDEF
bundle requires a paradigm shift from silo-based care to team based coordinated patient care.
The bundle challenges the healthcare cultural models, necessitating practice change,
collaboration across disciplines, and innovation in care delivery (Costa et al., 2017; Grol &
Grimshaw, 2003; Hermes et al., 2018).
In a literature review of team training in the ICU, Low et al. (2018) found team skills
training in the ICU facilitated clinical learning, improved staff behaviors, and was positively
received. The evidence suggests that implementing team training would promote
interprofessional collaboration and mitigate the hierarchical cultural models. The team training
would also assist in cultivating the trust needed to support interprofessional practice. Clark
(2003) notes that a lack of trust will destroy the team's motivation to accomplish goals. The
evidence implies that providing team-based training will not only increase the collective efficacy
of the Clinical Team but will also promote nonhierarchical practice and foster the trust needed
for ABCDEF bundle execution.
Cultural Settings

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The cultural setting was an observed strength at the Medical Center during the study. To
improve and sustain the Clinical Team’s ABCDEF bundle performance, the researcher grounded
the recommendations in organizational change theories. Clark and Estes (2008) state that
effective (a) change efforts ensure that everyone has the resources (equipment, personnel, time,
etc) needed to do their job, and that if there are resource shortages, then resources are aligned
with organizational priorities; (b) organizations ensure that organizational messages, rewards,
policies and procedures that govern the work of the organization are aligned with or are
supportive of organizational goals and values. The researcher recommends alignment of use of
the ABCDEF bundle to organizational priorities, demonstrated by providing the resources
needed (job aids, training time, feedback mechanisms) to allow the Clinical Team time to receive
knowledge on the bundle. Moreover, the organization should ensure the incorporation of the
ABCDEF bundle into organizational goals and incentive plans. An incentive structure aligned
with organizational goals is more important than the type of incentive used (Elmore, 2002).
Clark (2003) emphasized the need for clear vision and goals to engage individuals and
inspire work motivation. Grossman and Salas (2011) support this claim, further stating that goal
setting can increase motivation. In addition to goals, Stolovitch et al. (2002) found that financial
incentive programs increase work performance more than 20% and upwards to 40%. From a
theoretical perspective, setting goals and providing appropriate financial incentives would
strengthen performance in adhering to the ABCDEF bundle.
Integrated Implementation and Evaluation Plan
To assess the effectiveness of the ABCDEF bundle implementation and the
aforementioned recommendations, the researcher leveraged the New World Kirkpatrick Model
as a framework for implementation and evaluation (Kirkpatrick, 2015). The model consists of

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four levels that assess the transfer of learning and its connection to organizational results
(Kirkpatrick & Kirkpatrick, 2016). The authors describe the four levels as (a) Level 4 Results,
such as achieving desired outcomes or leading indicators; (b) Level 3 Behavior, pertaining to
application of learning on the job; (c) Level 2 Learning, as in attaining knowledge, skills, and
attitudes; (d) Level 1 Reaction, relating to learning engagement. The following section explores
the application of the four levels to the ABCDEF bundle to maximize the effectiveness of
implementing the novel approach into daily practice.
Organizational Purpose, Need and Expectations
The Medical Center exists to provide exceptional care to the community it serves. The
leadership of the organization has set a vision to lead the medical community in delivering
cutting edge, high quality, innovative patient care. This vision includes translating evidence-
based medicine into daily practice. This vision specifically relates to the organizational goal of
implementing the innovative care approach, known as the ABCDEF bundle, to 95% or greater of
the patients in the ICU for every shift by December 2025. Implementation of the bundle is
known to optimize healing and provide better patient outcomes to the acutely ill treated in the
ICU, but fails to be widely adopted in practice (Boehm et al., 2016; Masica et al., 2015; Miller et
al., 2015; Pun et al, 2019). The recommendations produced by this study intend to aid the
Medical Center in improving ABCDEF bundle adherence across the clinical teams that serve the
ICU.
Level 4: Results and Leading Indicators
Level 4 of the Kirkpatrick model associates learning to high level organizational
performance results (Kirkpatrick & Kirkpatrick, 2016). In the case of the Medical Center, this
translates to publicly reported rankings and key quality of care indicators. Achieving gains in the

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key quality indicators, such as mortality rate, directly affect the Medical Center’s rating in public
rankings. Table 16 outlines the external and internal outcomes related to the ABCDEF bundle
implementation.
Table 16
Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Increased publicly reported
ranking in US best
hospitals report
Number on the US News
and World Report
Ranking
Annual ranking reports released
in August annually
Increased publicly reported
star rating in Leapfrog
Hospital Safety Grade
Number on the Leapfrog
star rating
Annual ranking report including
mortality rates and length of stay
Increased publicly reported
ranking in Vizient quality
benchmarking
Number on the Vizient
quality of care ranking
Annual ranking report including
mortality rates, length of stay and
mechanical ventilation hours
Uphold accreditation
Joint Commission, Center
for Medicare and
Medicaid Department of
Public Health
Bi-annual accreditation review
including mortality rates and
length of stay
Internal Outcomes
Decreased Mortality Rates
Mortality Rates = patient
expired during hospital
stay or ICU stay
Gather data directly from the
Medical Centers EMR.
Calculation from ICU liberation
compliance calculations (Pun et
al, 2019)
Increased Delirium Free
Days
Number of Delirium Free
Days = length of days
without delirium.
Gather data directly from the
Medical Centers EMR.
Calculation from ICU liberation
compliance calculations
Decreased ICU and
Hospital Length of Stay
Length of Stay =
Discharge time-admission
time
Gather data directly from the
Medical Centers EMR.
Calculation from ICU liberation
compliance calculations
Reduction in Mechanical
Ventilation Hours
Mechanical Ventilation
Hours = Discharge vent
time - intubation time
Gather data directly from the
Medical Centers EMR.
Calculation from ICU liberation
compliance calculations

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Level 3: Behavior
Level 3 refers to the application of learning on the job following a training intervention
(Kirkpatrick & Kirkpatrick, 2016). This level surpasses assessment into ongoing performance
management and a comprehensive improvement system. Level 3 encompasses the critical
behaviors that need to change to achieve level 4 goals, the required drivers needed to drive
change in critical behaviors, and identifies organizational support that is needed within the
organization.
Critical Behaviors. At this step in the Kirkpatrick model, the critical behaviors required
to achieve level four are specified, observed, and measured. Each critical behavior is defined by
the metrics, methods, and timing to achieve behavior change. Table 17 reviews the critical
behaviors needed for the implementation of the ABCDEF bundle.
Table 17
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical
Behavior
Metric(s) Method(s) Timing
The Clinical
Team perform
the ABCDEF
bundle on a
daily basis
Number of items
documented in the EMR
for ABCDEF bundle
performance. Equivalent
to percent ABCDEF
Bundle Compliance;
percent of Partial
ABCDEF Bundle
compliance; percent of
Individual Element
Compliance
1. Critical Care
Administration
shall gather data
directly from the
Medical Centers
EMR.
Calculation from
ICU liberation
compliance
calculations.
2. ICU Physician
Attending and
Nurse Manager
shall observe
staff performance
of bundle
3. Nurse Lead shall
perform
documentation
audits

1. Weekly
given
limitations
in
Information
Technology
(IT). Near
real-time if
IT can be
optimized.
2. Daily
3. Daily

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The Clinical
Team coordinate
care across
multiple
disciplines on a
daily basis
1. Number of
multiprofessional
rounds where job
aid is used
2. Percent of whole
bundle versus
percent of
element bundle
compliance
comparison
3. Number of
escalations to
multidisciplinary
leaders,
including
number of safety
risk management
reports
4. Number of
positive survey
responses
1. Critical Care
Administration
shall perform
observation
audits
2. Critical Care
Administration
shall gather data
directly from the
Medical Centers
EMR
3. Clinical Team
shall report to
Critical Care
Administration.
Critical Care
Administration
shall collate and
communicate
number of
reports during
monthly working
group meeting
4. Critical Care
Administration
shall disseminate
an electronic
survey
1. Weekly
2. Weekly
3. Daily in
real-time
4. Quarterly
The Clinical
Team must
review the
ABCDEF
bundle
compliance
reports provided
to reflect on
performance and
course correct at
minimum on a
weekly basis
Number of touch points
for team review during
staff meetings, huddles,
or rounds
1. Critical Care
Administration
team shall
perform
observation
audits
2. Unit leadership
shall self-report
out during
monthly working
group meeting
1. Weekly
2. Monthly
The Medical
Director and
Nurse Manager
actively
collaborate and
coordinate unit
1. Number of times
Medical Director
is present at
Nurse staff
meetings and
vice versa
1. Critical Care
Administration
team shall review
attendance lists
of Nurse and
1. Monthly
2. Weekly

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operations
weekly at
minimum
2. Number of unit
leader huddles
per week
Physician staff
meetings
2. Critical Care
Administration
team will
perform
observation
audits
Required Drivers. Level three also includes required drivers, which reinforce critical
behaviors through accountability and support (Kirkpatrick & Kirkpatrick, 2016). The required
drivers are broken up into four categories, including monitoring, reinforcing, encouraging, and
rewarding. Table 18 explores the required drivers in each classification that fuel ABCDEF
bundle adoption.
Table 18
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical
Behavior
s
Supporte
d
1, 2, 3
Etc.
Reinforcing
Provide the Clinical Team with team-based training (Clinical
Education Dept)
Ongoing 1, 2
Provide team leader training to physicians and nurse leads
(Clinical Education Dept)
Ongoing 1, 2
Provide job aids to the Clinical Team on roles and
responsibilities, sequencing, and compliance reports for
ABCDEF bundle implementation (CC Administration)
Ongoing 1, 2, 3
Provide time in huddles to care coordinate and discuss
ABCDEF bundle implementation plan of care (Clinical Team)
Daily 1, 2
Require annual clinical competency validation of ABCDEF
bundle processes of care (Unit Leadership)
Annual 1, 2, 3
Provide goals for ABCDEF bundle compliance in broad
organizational goals (Unit Leadership)
Annual 1, 2
Provide key performance indicators for ABCDEF bundle
compliance in Medical Director and Nurse Manager job
descriptions (Medical Center Leadership)
Ongoing 3, 4

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Provide feedback and counseling to underperforming units,
teams, and individuals (Unit Leadership, CC Administration)
Ongoing 1, 2, 3, 4
Encouraging
Feedback and coaching from Clinical Team members and
disciplines leads (Unit Leadership, Clinical Team, CC Admin)
Ongoing 1, 2, 3
Remind the Clinical Team members of the value of ABCDEF
bundle implementation through education and training efforts
(Clinical Education, Unit Leadership)
Ongoing 1, 2, 3
Rewarding
Performance incentive when the Clinical Team meet ABCDEF
bundle compliance goals (Medical Center Leadership, Unit
Leadership)
Annually 1, 2, 3, 4
Public acknowledgement at multidisciplinary ICU meetings,
unit team meetings, unit boards, and in the Medical Center
news (Medical Center Leadership, Unit Leadership)
Ongoing 1, 2, 3, 4
Gamify compliance reports by providing comparison reports of
unit’s compliance across all ICUs and highlighting top unit
performers (CC Administration, Unit Leadership)
Ongoing 1, 2, 3, 4
Monitoring
Medical Center leadership, unit leaders, and the Clinical Team
can monitor their ABCDEF bundle compliance (CC
Administration)
Monthly,
Weekly,
Daily
1, 2, 3, 4
Medical Center leadership, unit leaders, and the Clinical Team
can monitor patient outcomes (CC Administration)
Monthly 1, 2, 3, 4
Multidisciplinary team leaders can assess performance and
feedback and counseling (Unit Leadership)
Ongoing 1, 2, 3

Organizational Support. The results and findings indicated that the cultural setting at
the Medical Center was a strength during the ABCDEF bundle implementation. To fortify this
strength and provide the organizational support to execute the required drivers, the organization
will need to maintain the ABCDEF bundle as an organizational priority. Specific goals that can
be measured should be encouraged to motivate individuals to achieve the goals (Clark & Estes,
2008, Dembo & Eaton, 2000). To demonstrate the bundle as an organizational priority, the
leadership can take several actions including (a) establishing the ABCDEF bundle as a standard
of care in the ICU; (b) inserting ABCDEF bundle targets in the annual performance incentive
programs; (c) placing key performance indicators focused on ABCDEF bundle compliance in

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unit leadership job descriptions; (d) investing in the resources needed to develop and distribute
job aids and the additional education and training outlined in the recommendations; (e) allocating
time for staff to attend ABCDEF bundle and team training including during new staff
orientation; (f) highlighting ABCDEF bundle performance in leadership communication; (g)
integrating ABCDEF bundle compliance review in organization performance reviews for the
Clinical Team; and (h) investing in information technology resources to provide ABCDEF
bundle compliance reports in real-time dashboards.
Level 2: Learning
Learning Goals. Implementing the recommendations described in Table 13, Table 14,
and Table 15 should result in the Clinical Team’s capability to perform the following:
1. Value the utilization of the ABCDEF bundle processes of care (utility value)
2. Summarize the roles and responsibilities associated with each discipline for
ABCDEF bundle implementation (F)
3. Classify the sequencing and steps for each of the bundle elements in appropriate
order to achieve whole bundle compliance (C)
4. Carry out the ABCDEF Bundle in daily practice collectively across disciplines (P)
5. Reflect on the ICU’s ABCDEF Bundle performance (M)
6. Integrate ABCDEF Bundle compliance reports in daily practice (P)
7. Assemble the interprofessional team to discuss the ABCDEF bundle care plan (C)
8. Design a multidisciplinary team ABCDEF bundle care plan (P)
9. Carry out the care coordination required for ABCDEF bundle adherence in
multidisciplinary rounds and during daily patient care activities (P)

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10. Be confident that all members of the team are performing their roles and
responsibilities (collective efficacy)
11. Attribute success and failure in ABCDEF bundle compliance to their collective
efforts (attribution)
12. Be confident in reading and interpreting compliance reports (self-efficacy)
13. Create action plans for improvement based on compliance report review (M)
14. Judge ABCDEF bundle compliance performance and provide feedback for
improvement (P)
Program. A multi-prong training approach is needed to sustain the strengths and
reinforce the areas of identified weaknesses across the knowledge, motivation, and organization
influences. Figure 17 illustrates the multidimensional training approach. To meet the learning
goals outlined in the previous section, team leader training, team training, and distribution of job
aids are recommended for an ABCDEF bundle training program. The training will have a
significant emphasis on delivering team skills, a major area for improvement that was identified
in the study. Bandura (2000) found that a high perception of collective efficacy can boost team
motivation and the probability of task success. The following section summarizes the content of
each training component beginning with team leader training, followed by an outline of the team
training workshop, and ending with job aids as bedside tools.
The climate of the team is influenced by the behavior of its leader (Cannon-Bowers &
Salas, 1998), hence the importance of incorporating team leader training into the ABCDEF
bundle training program. A train-the-trainer model will be leveraged to facilitate small group or
1:1 training live in the ICU to minimize disruption to unit operations caused by removing staff
from the unit for training and allow for a team mentoring model. Team mentoring models have

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shown the benefits of (a) shared responsibility to reduce the load on any individual mentor; (b)
perspective diversity; and (c) ongoing support for trainees (Caldwell et al., 2008). The identified
team leaders from each discipline will spend time with a team mentor discussing feedback
focused on motivating individuals and teams. The discussion would include the value of
feedback, positive and negative approaches, and constructive versus destructive criticism. The
concept discussion would include examples of feedback in a role play manner with
simulation. Team leaders will then exercise the learning during ABCDEF bundle presentation
during team huddles and rounds. Team leaders will then touch base with team mentors to reflect
on their performance and that of the team. Team leaders will meet with team mentors for
metacognition discussions on a weekly basis for a period of two months. The sessions would
continue as needed during the implementation and monitoring of the ABCDEF bundle.
Team-based training should occur in a multidisciplinary fashion where elements of the
ABCDEF bundle and the points of care coordination are modeled and practiced by the
interprofessional team. In their seminal work, Paris et al. (2000) suggested incorporating
individual and team skills evenly within a single education experience to maximize training
productivity. This shared learning experience will aim to connect the individual processes of care
to the collective process needed for whole bundle compliance. The program should be
synchronous, spanning a four-hour period. The training will open with emphasis on the value of
implementing the ABCDEF bundle by way of improved outcomes nationally and locally at the
Medical Center. It will then take a pedagogical review of the bundle and lead into the concept
and competencies needed to enhance teamwork. Teamwork skills are an essential component of
training as Cannon-Bowers and Salas (1998), in their foundational study, found that team
performance was positively influenced by teamwork skills training. The remaining time of

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training will focus on role play and simulation of interprofessional communication, care
coordination, delivery of feedback, then hands-on practice through simulation, and cross training
in smaller interdisciplinary break-out groups. Teams that cross train by rotating positions to gain
the perspective and knowledge of a team member with differing skills are known to outperform
those that do not participate in that type of exercise (Cannon-Bowers & Salas, 1998).
Following practice, teams will be encouraged to rehearse self-correction. Team self-
correction is used to diagnose issues with the team’s processes and facilitate the creation of
solutions to address performance issues (Cannon-Bowers & Salas, 1998). Lessons learned from
break-out groups will be shared and discussed broadly in the large group. Grossman and Salas
(2011) endorse this approach, stating “behavioral modeling facilitates transfer when both
positive and negative models are used, and when opportunities to practice are provided” (p. 107).
Training will close with a review of the tools available to the team including the job aids, and
asynchronous online videos reviewing the clinical science and background of each process of
care and the bundle as a whole. Clinical Team performance debriefing will occur during staff
meetings, daily huddles, and patient rounds to celebrate success and discuss areas of
improvement, lessons learned, and course correction where necessary.
ABCDEF bundle compliance increased with statistical significance, however the gap
between performance and goal led to the recommendation of providing job aids to the clinical
staff in complement to the existing clinical education on the ABCDEF bundle. Job aids for (a)
roles and responsibilities; (b) appropriate ABCDEF bundle element sequencing; (c) compliance
documentation and report interpretation; and (d) care coordination during rounds and throughout
daily practice should be reviewed in multiple arenas for familiarization and disseminated for
asynchronous study and utilization. The ICU medical director and nurse manager will review the

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job aids in staff and unit practice council meetings to acquaint staff on the tools and
communicate their use as an expectation on the unit. Selected physician and nurse lead on the
unit will then model the use of job aids in the unit’s daily huddle and patient care rounds.
Checklist focused job aids will be posted in patient rooms or added to patient white boards for
daily clinical use and clinician to clinician shift hand-off communication. The individuals on the
units will then practice the implementation of the ABCDEF bundle with job aids to build
procedural knowledge skills and receive feedback from their discipline leads or team mentors to
promote confidence in their abilities. Figure 17 is a visual depiction of the training program
outlined.
Figure 17
Training Program
Evaluation of the Components of Learning. Evaluation of the learning gleaned from
the ABCDEF bundle training program described in the previous section is needed to assess the
efficacy of the training in meeting the learning objectives. Clark (2005) indicates that individuals

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must believe that their contributions to a team are continuously and equitably assessed with team
performance. Defining the evaluation criteria will aid in setting the expectations of the Clinical
Team. Table 19 delineates the components of evaluation paired with the timing to guide the
components of learning.
Table 19
Evaluation of the Components of Learning for the Program
Methods or Activities Timing
Declarative Knowledge “I know it.”
Knowledge checks through discussion During synchronous training and 1:1
with team mentor
Multidisciplinary report out during daily patient
rounds
Daily during the training program
Procedural Skills “I can do it right now.”
Role play during training During synchronous training
Competency validation (Garman & Scribner, 2011)
by Clinical Educator
Within a month of the synchronous
training
Application of ABCDEF bundle processes of care Daily during the program
Attitude “I believe this is worthwhile.”
Pulse survey Three months following the
synchronous training
Observations by unit leadership and critical care
administration
Monthly during the program
Sustained practice of ABCDEF bundle processes of
care
Daily during the program
Confidence “I think I can do it on the job.”
Pulse surveys with confidence interval scales Three months following the
synchronous training
Team Mentor Discussions Weekly and ad hoc during the program
Commitment “I will do it on the job.”
Compliance performance results Weekly during the program
Team Mentor Discussions Weekly and ad hoc during the program
Incorporation into unit and individual goals By the end of the training program

Level 1: Reaction
The first level of the Kirkpatrick model relates to the extent trainees feel the education or
training is pertinent to their work, advantageous, and well received (Kirkpatrick & Kirkpatrick,

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2016). The authors stress that the timing of level one evaluation is an important factor to
consider as the perception of the quality of the training program may change following
application of the concepts learned in practice. Table 20 summarizes the level one assessment
methods of the proposed training program.
Table 20
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observation by instructor During synchronous training
Observation by team mentor During mentor sessions and on unit
Course Evaluation At the close of synchronous training
Relevance
Course Evaluation At the close of synchronous training
Live feedback requested from instructor During synchronous training
Customer Satisfaction
Course Evaluation At the close of synchronous training
Pulse Surveys Three months following the synchronous
training
Evaluation Tools
Immediately Following the Program Implementation. An evaluation tool will be
distributed after the synchronous training session focused on assessing level one and level two of
Kirkpatrick’s model. The evaluation tool is shown in Appendix I. A blend of Likert scale,
confidence intervals, and knowledge check questions are shown in the categories of level one
and two. Level one questions focus on trainee engagement, while level two questions refer to the
learning from the synchronous team training portion of the program.
Delayed for a Period After the Program Implementation. To measure the impact of
all four levels, an evaluation tool will be sent three months following the program
implementation. The time period will allow for observation of behavior change and results. The

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evaluation tool is shown in Appendix B. The questions on the tool aim at assessing the entire
training program, including the job aids, team leader training, and team training. A combination
of Likert scale, confidence interval, and knowledge checks are also used to evaluate all four
levels of the Kirkpatrick model. Like the evaluation tool designed for immediately following the
training, level one questions focus on participant satisfaction and level two targets knowledge
acquisition. Level three and four questions target the evaluation of knowledge application and
whether target outcomes were achieved. The degree to which teamwork skills were gained and
translated into daily practice is a significant focus of the tool, given the focus on increasing the
collective efficacy of the Clinical Team to improve ABCDEF bundle compliance.
Data Analysis and Reporting. The same methods to analyze the staff engagement
surveys in this study will be used to analyze and report the results of the training program
evaluation. Appendix F shows examples of how the tables and charts will be created to display
results using notional data. Appendix C demonstrates a sample infographic that pairs the
ABCDEF bundle compliance results with the responses of the training evaluation tool. The
sample infographic will provide high level status reports to stakeholders on performance
progress. The Critical Care Administration team will ensure dissemination and receipt of
evaluation tools immediately following training and three months after. Additional detailed
infographics will be created to display key results and present as an executive summary to the
Critical Care Leaders.
Summary
The New World Kirkpatrick Model is a refreshed version of a seminal framework used to
maximize the value of training approaches (Kirkpatrick & Kirkpatrick, 2016). The model’s four
levels evaluate specific areas of training to understand the reaction, learning, behavior, and

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results derived from a training program. The New World Model reverses the approach of the
original model, encouraging trainers to set metrics for reviewing their training approach from
level four to level one on an ongoing basis. The model started with outcomes and worked
backward to devise strategies on how to achieve results. The researcher used the model to design
a training program to bridge the gap between stakeholder performance and goal. Evidence-based
recommendations were outlined to optimize strengths and address weaknesses identified in the
validation of the knowledge, motivation, and organization influences of the Clark and Estes
(2008) gap analysis framework. The high-level outcomes were identified in level four, defining
both external and internal desired results. Level three pinpointed the critical behaviors and the
required drivers needed to promote Clinical Team behavior changes to reach the level four
outcomes. Level two defined the learning goals, training activities, and components of evaluation
to drive level three behavior change. The final level one established evaluation tools and a data
analysis approach to measure and report trainee engagement. Integrating the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) with the knowledge, motivation and
organization recommendations aided the researcher in providing an action based approach to
bolster the Clinical Team’s performance with an evaluation framework to ensure a return on the
training investment. This approach supported defining and continuously measuring value to
garner organizational support and Clinical Team commitment to engaging in ABCDEF bundle
performance improvement.
Implications for Practice
The ABCDEF bundle is a recognized approach to improving patient outcomes in the
critically ill patients served in the ICU (Boehm et al., 2016; Masica et al., 2015; Miller et al.,
2015; Pun et al, 2019). Although well known, the bundle has yet to be a widely and consistently

138

adopted approach for care (Boehm et al., 2016; Boltey et al., 2019; Masica et al., 2015; Miller et
al., 2015). The improved patient outcomes observed in this study affirmed the need to implement
the ABCDEF bundle into practice. Specifically, implementation of the whole bundle compared
to partial completion resulted in an 87% reduced chance of death. Although partial compliance
led to improvement in some key patient outcomes, this finding emphasized the importance of
practicing the entire ABCDEF bundle in daily practice to reduce mortality.
A gap in the literature was found during the study, the researcher did not find studies that
expanded beyond the clinical science of ABCDEF bundle implementation. Barriers to adoption
of the bundle were cited at a high level, but an in-depth look at how to mitigate the barriers to
achieve whole bundle compliance through a gap analysis and training program with rigorous
evaluation was not found. This study contributes to medical knowledge by examining the
knowledge, motivation, and organization influences during ABCDEF bundle implementation
and deriving recommendations to address the gap in performance related to achieving whole
bundle compliance. The study identified the need to incorporate a significant focus on
developing teamwork skills among the Clinical Team by actively integrating team leader support
and team skills training in ABCDEF bundle training. Incorporating a structure for accountability
to ensure the ABCDEF bundle is integrated into daily workflow through monitoring, feedback,
and reflection was also a key recommendation to increase ABCDEF bundle compliance. In
addition, recommendations suggested aligning ABCDEF bundle performance with goals and
incentive plans to emphasize organizational importance of the implementation. Furthermore,
several studies underlined the importance of data in real-time to evaluate progress and take
action towards improvement in real-time (Barnes-Daly et al., 2018; Bassett et al., 2015; Proctor
et al., 2015; Pun et al., 2019). This study validated the Clinical Team’s need for data accessibility

139

to reflect on performance and drive improvement. The global healthcare industry may use the
evidence and recommendations found in this study and directly apply it as a practical approach
to ABCDEF bundle implementation that will aid in shifting the siloed based healthcare culture to
that of collaboration and interprofessional practice.
Future Research
This study focused on the implementation of the ABCDEF bundle in four of the eight
ICU’s of the Medical Center. Altering the implementation approach of the bundle to incorporate
the recommendations of this study and monitoring results would be the logical next step for
future research. Three additional studies could be conducted to expand on the findings of this
study including (a) comparison of the compliance results between the initial four units to the
implementation results of the next four units; (b) analyzing the compliance results in this study
against the results following implementation of the recommended training program on the
original units; and (c) the sustainability of performance results longitudinally. These studies
could be used to enhance, support, or uncover additional strategies to increase ABCDEF bundle
compliance over the long term.
Incorporating a mixed method study that compares quantitative results with qualitative
data could also enrich the study findings. Qualitative data would aid in deriving meaning that
may not be captured in the high-level quantitative results (Merriam & Tisdell, 2016). A
qualitative aspect of a study focused on ABCDEF bundle implementation would provide a
deeper dive into how barriers manifest in daily work and how the staff perceive success or failure
in achieving bundle goals. This study could be used to assess the performance goal, and whether
the IHI 95% goal (Resar et al., 2012) is realistic given the complexity of ABCDEF bundle
delivery.

140

Conclusions
This study sought to explore the knowledge, motivation, and organization influences
associated with the implementation of a novel clinical bundle protocol known as the ABCDEF
bundle. Known to improve patient outcomes, translating this evidence-based protocol into
practice has been a challenge in the medical community (Boehm et al., 2016; Boltey et al., 2019;
Masica et al., 2015; Miller et al., 2015). The Clark and Estes (2008) gap analysis framework was
used to study the ABCDEF bundle implementation across four ICUs of the Medical Center.
Knowledge, motivation, and organization influences were validated and assessed as strengths or
weaknesses that were addressed by evidence-based recommendations. The recommendations
proposed a training program focused on bridging knowledge and motivation gaps of individual
members and the Clinical Team as a whole. The training proposed based on the study
recommendations followed the New World Kirkpatrick Model, which outlined a multi-level
evaluation used to ensure that training yields results across trainee reaction, learning, behavior
change, and outcomes (Kirkpatrick & Kirkpatrick, 2016).
The evidence produced from this study will directly benefit the medical community. The
ABCDEF bundle implementation process used at the Medical Center produced a statistically
significant increase in ABCDEF bundle adherence, well above the national average achieved
during the seminal study of ABCDEF bundle impact (Pun et al., 2019). The compliance review
and staff engagement survey conducted in the study identified strengths that needed to be
sustained and weaknesses that needed to be reinforced to bridge the gap between performance
and goal. A key element needed to close the gap was the cultural barrier of siloed patient care
experienced across the medical community (Alexanian et al., 2015; Manthous & Hollingshead,
2011). The ABCDEF bundle requires interprofessional collaboration and care coordination

141

(Bassett et al., 2015; Barnes-Daly, Phillips & Ely, 2017; Barnes-Daly et al., 2018; Boehm et al.,
2016; Boltey et al., 2019; Bounds et al., 2016; Hermes et al., 2018; Kram et al., 2015). The
results and findings indicated collective efficacy as an area of improvement for the Clinical
Team to achieve whole ABCDEF bundle compliance targets. The training program targeted
imparting team skills in a shared learning environment that combined ABCDEF bundle clinical
education with the incorporation of modeling, practice, and feedback. The evaluation tools were
developed to assess training effectiveness at the onset of training, and beyond to gauge the
achievement of long-term behavior change and outcome results. In conclusion, the evidence
generated in this study can be replicated and customized for any medical institution as they
approach translating evidence-based medicine in Critical Care and beyond.

142

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Appendices
Appendix A: Implementation Timeline
ABCDEF bundle implementation timeline at the Medical Center. For the purposes of the study,
research will focus on units 1, 2, 3 and 4.
Figure 18
Implementation Timeline

156

Appendix B: Survey Items
Survey Questions
Demographics
Unit: 1, 2, 3, 4, 5, 6, 7, 8 [Can select multiple units]
Role: Physician, Nurse, RT, PT, NP, Case Manager, Social Worker, Other
Table 21
Detailed Survey Questions

Subcategory Question # Question Detail
Knowledge
Conceptual
Q9_4
Having access to data is essential to managing
ABCDEF bundle compliance
Conceptual
Q9_5
I feel the A-F compliance reports helped in managing
my performance with ABCDEF bundle
implementation
Metacognitive
Q9_7
A-F compliance reports improved my ability to
interpret data
Metacognitive
Q17_4
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
Ability to read and interpret ABCDEF data reports
BEFORE data literacy training
Metacognitive
Q17_5
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
Ability to read and interpret ABCDEF data reports
AFTER data literacy training
Metacognitive
Q17_7
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
Learning how to perform the bundle was easy for me
Procedural
Q9_8
I feel I have the skills to read and interpret data
reports
Procedural
Q17_10
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
Monitoring my unit's compliance to the ABCDEF
bundle
Conceptual
Q16_9
Using the A-F compliance reports improves my
compliance to the ABCDEF bundle
Conceptual
Q9_1
Using data in patient care and management is a good
idea

157

Conceptual
Q9_2
Using data in patient care and management is
unpleasant
Conceptual
Q9_3
Using data is beneficial to my patient care and
management
Factual
Q16_12
I understand my role and responsibilities for
ABCDEF bundle implementation
Metacognitive
Q9_6
I feel able to understand data related to the ABCDEF
bundle
Motivation
Self-Efficacy
Q17_1
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
Performing the ABCDEF bundle on patients in my
unit daily
Self-Efficacy
Q17_9
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
All members of the clinical team are performing the
bundle when indicated that it is appropriate for
patient care
Utility Value
Q9_16
I feel ABCDEF bundle compliance improved with
the implementation of A-F compliance reports
Utility Value
Q18_1
I feel the implementation of the bundle increased
patient outcomes
Utility Value
Q18_2
I feel the implementation of the bundle decreased
patient outcomes
Utility Value
Q18_3
I feel the implementation of the bundle didn't affect
patient outcomes
Utility Value
Q17_6
Rate your degree of confidence by recording a
number from 0 to 100 using the scale given below: -
The ABCDEF bundle improves patient care and
outcomes
Utility Value
Q16_13
The amount of work I am expected to complete to
implement the bundle is reasonable
Organization
Leadership
Support
Q16_10
My department provided all the tools I needed to be
successful to perform this bundle in daily practice
Leadership
Support
Q16_11
I received the support I needed from the
administration team throughout the implementation
of the A-F compliance report
Training
Q16_1
I am satisfied with the clinical education and training
I received for: - A

158

Training
Q16_2
I am satisfied with the clinical education and training
I received for: - B
Training
Q16_3
I am satisfied with the clinical education and training
I received for: - C
Training
Q16_4
I am satisfied with the clinical education and training
I received for: - D
Training
Q16_5
I am satisfied with the clinical education and training
I received for: - E
Training
Q16_6
I am satisfied with the clinical education and training
I received for: - F
Training
Q16_7
I am satisfied with the clinical education and training
I received for: - The entire ABCDEF Bundle
Training
Q16_8
I feel I received enough training to use the A-F
compliance reports to manage my units ABCDEF
bundle compliance
Trust
Q9_9
I experienced good collaboration with nurses during
implementation
Trust
Q9_10
I experienced good collaboration with physicians
during implementation
Trust
Q9_11
I experienced good collaboration with Physical
Therapy during implementation
Trust
Q9_12
I experienced good collaboration with Respiratory
Therapy during implementation
Trust
Q9_13
Collaboration improved across disciplines with the
implementation of the ABCDEF Bundle
Trust
Q9_14
Interprofessional collaboration increased with
ABCDEF bundle implementation
Trust
Q9_15
Collaboration improved across disciplines with the
implementation of the A-F compliance reports

159

Appendix C: Survey Demographics and Response Rates
Table 22
Survey Recipients by Role
Role Frequency Percent
Physician 64 17%
Nurse 158 41%
RT 128 33%
PT/OT 22 6%
NP 6 2%
Case Manager 3 1%
Social Worker 3 1%
Other 2 1%
Total 386 100%

Table 23
Survey Respondents by Role
Role Frequency Percent
Physician 47 15%
Nurse 153 48%
RT 84 26%
PT/OT 21 7%
NP 6 2%
Case Manager 3 1%
Social Worker 3 1%
Other 2 1%
Total 319 100%

Table 24

Survey Response Rate by Role
Role Rate
Physician 73%
Nurse 97%
RT 66%
PT/OT 95%
NP 100%
Case
Manager 100%

Social
Worker 100%

Other 100%

160

Table 25
Survey Item Response Rates
Item Response Rate Response Rate Item Response Rate Response Rate
Q9_1 100% Q17_5 69%
Q9_2 100% Q17_6 70%
Q9_3 100% Q17_7 71%
Q9_4 100% Q17_9 71%
Q9_5 100% Q17_10 69%
Q9_6 100%
Q9_7 100%
Q9_8 100%
Q9_9 100%
Q9_10 100%
Q9_11 100%
Q9_12 100%
Q9_13 100%
Q9_14 100%
Q9_15 100%
Q9_16 100%
Q18_1 100%
Q18_2 99%
Q18_3 99%
Q16_1 88%
Q16_2 87%
Q16_3 86%
Q16_4 86%
Q16_5 85%
Q16_6 85%
Q16_7 89%
Q16_8 90%
Q16_9 90%
Q16_10 90%
Q16_11 90%
Q16_12 91%
Q16_13 90%
Q17_1 71%
Q17_4 69%

161

Appendix D: Knowledge Survey Results
Factual Knowledge
Table 26
Survey Responses
Q16_12

I Understand my Role and Responsibilities for
ABCDEF Bundle Implementation
Response Frequency Percent
Strongly Agree 77 27%
Agree 141 49%
Somewhat Agree 51 18%
Somewhat Disagree 11 4%
Disagree 3 1%
Strongly Disagree 7 2%
Total 290 100%

Conceptual Knowledge
Table 27
Survey Responses

Q9_1

Q9_2

Q9_3

Using Data in Patient
Care and
Management is a
Good Idea
Using Data in Patient
Care and
Management is
Unpleasant
Using Data is
Beneficial to my
Patient Care and
Management
Response Frequency Percent Frequency Percent Frequency Percent
Strongly Agree 167 52% 18 6% 160 50%
Agree 127 40% 26 8% 128 40%
Somewhat Agree 16 5% 18 6% 22 7%
Somewhat Disagree 4 1% 34 11% 3 1%
Disagree 0 0% 120 38% 2 1%
Strongly Disagree 5 2% 103 32% 4 1%
Total 319 100% 319 100% 319 100%

Q9_4

Q9_5

Q16_9

Having Access to
Data is Essential to
Managing ABCDEF
Bundle Compliance
I feel the A-F
Compliance Reports
Helped in Managing
my Performance
Using the A-F
Compliance Reports
Improves my

162

with ABCDEF
Bundle
Implementation
Compliance to the
ABCDEF Bundle
Response Frequency Percent Frequency Percent Frequency Percent
Strongly Agree
143
45%
84
26%
51
18%
Agree 134 42% 120 38% 124 43%
Somewhat Agree
28
9%
65
20%
66
23%
Somewhat Disagree 8 3% 27 8% 23 8%
Disagree 2 1% 13 4% 17 6%
Strongly Disagree 4 1% 10 3% 7 2%
Total 319 100% 319 100% 288 100%

Procedural Knowledge
Table 28
Survey Responses
Q17_10

Q17_10
All Members of the Clinical Team are
Performing the Bundle when Indicated that it
is Appropriate for Patient Care

Monitoring my Unit's Compliance
to the ABCDEF Bundle
Response Frequency Percent

Calculation Value
0-10 5 2%

Mean 74.79
11-20 4 2%

Median 80.00
21-30 2 1%

Mode 100.00
31-40 4 2%

Var 537.68
41-50 21 10%

Std Dev 23.19
51-60 25 11%

Min 0.00
61-70 18 8%

Max 100.00
71-80 44 20%

Range 100.00
81-90 30 14%

Q1 60.00
91-100 68 31%

Q2 80.00
Total 221 100%

Q3 94.00

Q4 100.00

IQR 34.00

Metacognitive Knowledge
Table 29
Survey Responses

163

Q17_4

Q17_5

Q17_7

Ability to Read and
Interpret ABCDEF
Data Reports Before
Data Literacy Training
Ability to Read and
Interpret ABCDEF
Data Reports AFTER
Data Literacy Training
Learning How to
Perform the Bundle
was Easy for Me
Response Frequency Percent Frequency Percent Frequency Percent
0-10 4 2% 2 1% 0 0%
11-20 3 1% 1 0% 2 1%
21-30 4 2% 1 0% 0 0%
31-40 6 3% 2 1% 1 0%
41-50 28 13% 13 6% 12 5%
51-60 21 10% 12 5% 23 10%
61-70 19 9% 20 9% 22 10%
71-80 39 18% 35 16% 36 16%
81-90 44 20% 60 27% 50 22%
91-100 53 24% 75 34% 80 35%
Total 221 100% 221 100% 226 100%

164

Appendix E: Motivation Survey Results
Utility Value Motivation

Table 30
Survey Responses

Q9_16

Q18_1

Q18_2

I Feel ABCDEF Bundle
Compliance Improved
with the
Implementation of A-F
Compliance Reports
I Feel the
Implementation of
the Bundle Increased
Patient Outcomes
I Feel the
Implementation of
the Bundle
Decreased Patient
Outcomes
Response Frequency % Frequency % Frequency Percent
Strongly Agree 70 22% 74 23% 13 4%
Agree 131 41% 128 40% 35 11%
Somewhat Agree 78 24% 78 25% 19 6%
Somewhat
Disagree 23 7% 21 7% 53 17%
Disagree 12 4% 11 3% 127 40%
Strongly Disagree 5 2% 6 2% 69 22%
Total 319 100% 318 100% 316 100%

Q18_3

Q16_13

I Feel the
Implementation of the
Bundle did not Affect
Patient Outcomes
The Amount of
Work I am Expected
to Complete to
Implement the
Bundle is
Reasonable

Response Frequency % Frequency %

Strongly Agree 15 5% 61 21%

Agree 40 13% 137 48%

Somewhat Agree 46 15% 60 21%

Somewhat
Disagree
52
17%
19
7%

Disagree 111 35% 5 2%

Strongly Disagree 51 16% 5 2%

Total 315 100% 287 100%

Q17_6

165

Rate Your Degree of Confidence by
Recording a Number from 0 to 100 Using the
Scale Given Below: - The ABCDEF Bundle
Improves Patient Care and Outcomes

Response Frequency %

0-10 3 1%

11-20 4 2%

21-30 2 1%

31-40 3 1%

41-50 11 5%

51-60 14 6%

61-70 18 8%

71-80 32 14%

81-90 47 21%

91-100 90 40%

Total 224 100%

Self-Efficacy Motivation

Table 31
Survey Responses

Q17_1

Q17_9

Performing the ABCDEF
Bundle on Patients in my
Unit Daily
All Members of the Clinical Team
are Performing the Bundle when
Indicated that it is Appropriate for
Patient Care
Response Frequency % Frequency %
0-10 2 1% 2 1%
11-20 1 0% 2 1%
21-30 0 0% 4 2%
31-40 1 0% 5 2%
41-50 10 4% 20 9%
51-60 14 6% 22 10%
61-70 14 6% 28 12%
71-80 38 17% 37 16%
81-90 50 22% 48 21%
91-100 97 43% 59 26%
Total 221 100% 227 100%

166

Appendix F: Organization Survey Results
Organizational Trust
Table 32
Survey Responses

Q9_9

Q9_10

Q9_11

I Experienced Good
Collaboration with
Nurses During
Implementation
I Experienced
Good
Collaboration
with Physicians
During
Implementation
I Experienced Good
Collaboration with
Physical Therapy
During
Implementation
Response Frequency %
Frequ
ency % Frequency %
Strongly Agree 99 31% 85 27% 73 23%
Agree 146 46% 130 41% 128 40%
Somewhat Agree 55 17% 73 23% 68 21%
Somewhat Disagree 11 3% 16 5% 27 8%
Disagree 7 2% 12 4% 16 5%
Strongly Disagree 1 0% 3 1% 7 2%
Total 319 100% 319 100% 319 100%

Q9_12

Q9_13

Q9_14

I Experienced Good
Collaboration with
Respiratory Therapy
During Implementation
Collaboration
Improved Across
Disciplines with
the
Implementation
of the ABCDEF
Bundle
Interprofessional
Collaboration
Increased with
ABCDEF Bundle
Implementation
Response Frequency %
Frequ
ency % Frequency %
Strongly Agree 85 27% 78 24% 80 25%
Agree 134 42% 137 43% 141 44%
Somewhat Agree 67 21% 70 22% 66 21%
Somewhat Disagree 17 5% 18 6% 16 5%
Disagree 8 3% 13 4% 13 4%
Strongly Disagree 8 3% 3 1% 3 1%
Total 319 100% 319 100% 319 100%

Q9_15

Collaboration
Improved Across

167

Disciplines with the
Implementation of the
ABCDEF Compliance
Reports
Response Frequency %

Strongly Agree
69
22%

Agree 138 43%

Somewhat Agree 69 22%

Somewhat Disagree 22 7%

Disagree 17 5%

Strongly Disagree 4 1%

Total 319 100%

Organizational Training
Table 33
Survey Responses

Q16_1

Q16_2

Q16_3

I am Satisfied with the
Clinical Education and
Training I Received for: -
A
I am Satisfied with the
Clinical Education and
Training I Received for:
- B
I am Satisfied with
the Clinical
Education and
Training I Received
for: - C
Response Frequency % Frequency % Frequency %
Strongly Agree 68 24% 65 23% 62 23%
Agree 140 50% 130 47% 136 50%
Somewhat Agree 46 16% 52 19% 51 19%
Somewhat Disagree 13 5% 15 5% 11 4%
Disagree 9 3% 10 4% 7 3%
Strongly Disagree 6 2% 7 3% 6 2%
Total 282 100% 279 100% 273 100%

Q16_4

Q16_5

Q16_6

I am Satisfied with the
Clinical Education and
Training I Received for: -
D
I am Satisfied with the
Clinical Education and
Training I Received for:
- E
I am Satisfied with
the Clinical
Education and
Training I Received
for: - F
Response Frequency % Frequency % Frequency %
Strongly Agree 62 23% 59 22% 64 24%
Agree 133 49% 139 51% 134 50%
Somewhat Agree 50 18% 47 17% 45 17%
Somewhat Disagree 14 5% 12 4% 13 5%

168

Disagree 8 3% 9 3% 8 3%
Strongly Disagree 6 2% 6 2% 6 2%
Total 273 100% 272 100% 270 100%

Q16_7

Q16_8

I am Satisfied with the
Clinical Education and
Training I Received for: -
The entire ABCDEF
Bundle
I Feel I Received
Enough Training to Use
the A-F Compliance
Reports to Manage my
Units ABCDEF Bundle
Compliance

Response Frequency % Frequency %

Strongly Agree 63 22% 51 18%

Agree 140 49% 128 44%

Somewhat Agree 55 19% 65 23%

Somewhat Disagree 12 4% 27 9%

Disagree 7 2% 10 3%

Strongly Disagree 6 2% 7 2%

Total 283 100% 288 100%

Figure 19
Organization Training

169

Organizational Leadership Support
Table 34
Survey Responses

Q16_10

Q16_11

My Department
Provided All the
Tools I Needed to be
Successful to
Perform this Bundle
in Daily Practice
I Received the Support I
Needed from the
Administration Team
Throughout the
Implementation of the
ABCDEF Compliance Report
Response Frequency % Frequency %
Strongly Agree 62 22% 57 20%
Agree 126 44% 126 44%
Somewhat Agree 71 25% 65 23%

24%
23%
23%
23%
22%
24%
50%
47%
50%
49%
51%
50%
16%
19%
19%
18%
17%
17%
5%
5%
4%
5%
4%
5%
3%
4%
3%
3%
3%
3%
2%
3%
2%
2%
2%
2%
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
A
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
B
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
C
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
D
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
E
I AM SATISFIED
WITH THE
CLI NI CA L
EDUCATION AND
TRAINING I
RECEIVED FOR: -
F
ORGANIZATION TRAINING
Strongly Agree Agree Somewhat Agree Somewhat Disagree Disagree Strongly Disagree

170

Somewhat Disagree 18 6% 26 9%
Disagree 7 2% 9 3%
Strongly Disagree 4 1% 4 1%
Total 288 100% 287 100%

171

Appendix G: Document Review
Figure 20
A Element Compliance
Figure 21
B Element Compliance

172

Figure 22
C Element Compliance

Figure 23
D Element Compliance

173

Figure 24
E Element Compliance
Figure 25
F Element Compliance

174

Figure 26
ABCDEF Bundle Compliance

Figure 27
ABCDEF Bundle Compliance by Unit

175

Appendix H: Sample Compliance Report
Figure 28
Sample ABCDEF Bundle Compliance Monthly Report

176

Figure 29
Sample ABCDEF Bundle Patient Outcomes Monthly Report

177

Appendix I: Evaluation Tool Immediately Following the Program Implementation

Level 1
Six-point Likert scales strongly disagree to strongly agree
1. I found this to be an effective use of my time.
2. I was motivated to perform the ABCDEF bundle.
3. I found the content was relevant to my job.
4. My learning was enhanced by this training.
5. I would recommend attending this training session to a colleague.

Level 2
1. What is Post ICU Syndrome (PICS)?
a. Collection of health disorders that are common among patients who survive
critical while in ICU
b. Presence of lethargy and sedation
c. Restlessness, agitation, hallucinations and delusions
2. How can you engage families while the patient is in the ICU?
a. Not including family members during rounds because they do not understand
medical terms
b. Failing to inform families to changes regarding the plan of care
c. Encouraging family members during rounds and allowing them to ask questions
3. What do the letters in ABCDEF each stand for? Please fill in the blank below
a. A:____________________________
b. B:____________________________
c. C:____________________________
d. D:____________________________
e. E:____________________________
f. F:____________________________
4. Six-point Likert scales strongly disagree to strongly agree
a. I feel I gained essential teamwork skills needed to perform the ABCDEF bundle.
b. I am more confident in performing the ABCDEF bundle now than before this
training
5. Rate your degree of confidence by recording a number from 0 to 100 using the scale
given below:
a. Perform the ABCDEF bundle on patients in my unit daily
b. Stating the frequency of each element of the ABCDEF bundle to reach whole
bundle compliance
c. Completing the ABCDEF bundle in the required sequence
d. Communicating the plan of care to members of the Clinical team
e. Coordinating care across multiple disciplines

Any additional feedback? Open Comment Box

178

Appendix J: Evaluation Tool Delayed for a Period After the Program Implementation

Level 1

1. I am satisfied with the clinical education and training I received for:
a. A
b. B
c. C
d. D
e. E
f. F
g. The entire ABCDEF Bundle
h. Care Coordination
i. Communication
j. Team Leader
2. The amount of work I am expected to complete to implement the bundle is reasonable
3. I found the job aids provided supported my ability to implement the ABCDEF bundle

Level 2
1. What is the GOAL of C?
a. Minimize the use of sedatives
b. Patient can rest without interruptions
c. Reduce patient’s anxiety
2. What is the GOAL of D?
a. Increase risk of mortality
b. Prolong ICU days
c. Prevention is the key to managing delirium
3. What is the GOAL of E?
a. Administration of pain medication
b. Early activity maximizes the patient’s mobility function
c. For physical therapists to assist with activities
4. Six-point Likert scales strongly disagree to strongly agree
a. I understand my role and responsibilities to implement the ABCDEF bundle
b. I trust my colleagues to perform the processes of care needed to reach ABCDEF
whole bundle compliance
c. The ABCDEF bundle is important to implement
5. Rate your degree of confidence by recording a number from 0 to 100 using the scale
given below:
a. Perform the ABCDEF bundle on patients in my unit daily
b. Communicate the plan of care to members of the Clinical team
c. I am more confident in performing the ABCDEF bundle now than before this
training

Level 3

179

1. Six-point Likert scales strongly disagree to strongly agree
a. I am using what I learned from the training in my daily work
b. Care coordination happens easily
c. There are no breakdowns in communication between team members
d. The team leader helps facilitate the implementation of the ABCDEF bundle
e. Feedback is given constructively
f. The feedback I receive motivates me to perform better
g. The organization's culture supports the collaboration required to coordinate care
2. All members of the clinical team are performing the bundle when indicated that it is
appropriate for patient care
3. Interprofessional collaboration increased with the training
Level 4
1. Six-point Likert scales strongly disagree to strongly agree
a. The training helped our ICU reach our goals
b. The team has performed better since attending the training
c. Staff satisfaction has improved since the training
d. I feel the implementation of the ABCDEF bundle (improved, hindered, didn’t
affect) patient outcomes
Any additional feedback? Open Comment Box

180

Appendix K: Sample Infographic for Data Analysis and Reporting
Figure 30
Infographic Sample

Abstract (if available)

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Asset Metadata

Creator Brown, Joan (author)

Core Title Translating evidence-based medicine into practice in critical care: an innovation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 10/16/2020

Defense Date 09/28/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag ABCDEF bundle,evidence-based medicine,ICU protocol,interprofessional clinical practice,OAI-PMH Harvest,post-ICU syndrome

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee chair), Cobb, J. Perren (committee member), Sullivan, Maura (committee member), Yates, Kenneth (committee member)

Creator Email joanbrow@usc.edu,joancbrown@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-383706

Unique identifier UC11665923

Identifier etd-BrownJoan-9043.pdf (filename),usctheses-c89-383706 (legacy record id)

Legacy Identifier etd-BrownJoan-9043.pdf

Dmrecord 383706

Document Type Dissertation

Rights Brown, Joan

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA