Connecting Nursing Theory and Evidence-based Change Models

The quality improvement includes safeguarding patients’ safety. Quality improvements are important and nursing and healthcare because they improve care efficiency, effectiveness, safety, and patient-centeredness. This is achieved by improving and updating the existing processes, procedures, and standards of practice and performance. Infections related to health care in the hospital are a major source of patient safety risks.

Connecting Nursing Theory and Evidence-based Change Models

This Direct Practice Improvement (DPI) project aims at improving the quality of care by understanding the determinants of Healthcare-Associated Infections (HAIs) and proposing the best evidence-based strategies. The execution of this project will be guided by a nursing theory and a change model. The purpose of this paper is to describe a nursing theory and a change model for this Direct Practice Improvement (DPI) Project.

Theoretical Foundations

Quality improvements in nursing are systematic and stepwise projects that require a guiding framework. Nursing theories provide a theoretical and conceptual approach that increases the likelihood of success in quality and change management. Each nursing theories and quality improvement model have its own pros and cons (Hamilton et al., 2020). Therefore, it is upon the quality improvement coordinator to select the theoretical model that best suits the approach and  objectives of the quality improvement project

Nursing Theory

Nursing theories present the testable relationship among variables in quality improvement and change. Middle-range nursing theories are more applicable to research and practice as they link the practice gap by providing assumptions for empirical generalizations. In this practice improvement initiative, the comfort theory by Kolcaba. This middle-range theory has been applied in various quality improvement research studies.

The Comfort Theory. Katharine Kolcaba’s comfort theory explains three aspects of patient care and nursing: ease, relief, and transcendence that move patients away from stressful situations. Meeting patients’ comfort needs leads to ease, relief, and transcendence.

In this theory, Kolcaba assumed that comfort is a holistic concept in nursing that nursing care must strive to achieve to sustain a good patient experience. The three theory factors (ease, relief, and transcendence) are important patient outcomes that patients with healthcare-associated infections desire to achieve.

According to Peterson & Bredow (2020), Kolcaba’s comfort theory is applicable to research in any setting where patient comfort is prioritized and valued. Performance improvement programs, quality improvement projects, and evidence-based practice have benefited from this theoretical framework.

This project aims to utilize primary evidence to improve patient care quality through infection prevention strategies. Therefore, assessing nurses’ knowledge about their patient comfort outcomes would provide a snapshot of the extent of knowledge improvement and patient safety.

Valuing patient comfort drives the nurses to ensure comfortable procedures such as infection prevention and other safety risks in the hospital. This theory originated from a series of works by Dr. Katherine Kolcaba (Peterson & Bredow, 2020). Her last research work leading to the refinement of the comfort theory in 2006 aimed at developing a unifying framework that would enhance the practice environment.

In the core framework of this theory, healthcare needs, nursing interventions over time, and other intervening variables lead to enhanced patient comfort. This comfort leads to good health-seeking behaviors to maintain health and prevent diseases. These behaviors can include patient engagement and nursing collaboration to enhance safety and quality.

Clinical Question. Nurses’ knowledge competency regarding patient safety can determine their capacity to promote patient comfort through risk prevention and reduction. Continuous and regular education should improve this competency through evidence-needs assessment and up-to-date interventions.

A baseline understanding of the nurses’ knowledge competency will provide a baseline for project assessment. Providing continuous nurse education is hypothesized to improve patient safety and thus comfort. The PICOT question for this project would read as follows:

To what degree does the implementation of regular nurses’ patient safety education (intervention) impact patient safety outcomes (what) when compared to no regular nursing education among adult patients admitted (population) in the inpatient units (setting) in _______ (state)?

Synthesis of Theory. Various nursing projects and nursing research studies have applied Kolcaba’s comfort theory. Ebrahimpour & Hoseini (2018) designed a nursing intervention for a pediatric cancer patient case scenario to enhance needs assessment and innovative care for other oncology patients.

Bergström et al. (2018) applied the comfort theory to ensure holistic care from nurse anesthetists by implementing comfort measures in the preoperative phase of care. Vo (2020) utilized comfort theory to design a practical guide for frontline healthcare workers during the COVID-19 pandemic. A study more related to this project was conducted by Simes et al. (2018) and found the need to handle personal, structural, and human resource barriers to improve comfort to offer holistic care.


Comfort theory has an essential framework that can be applied by this project to improve outcomes in HAI prevention. Related to physical comfort is the need to utilize all interventions that would promote relief, including safety from infections. Overall quality and safety in HAI prevention will also gain from addressing other interventions such as psychospiritual, environmental, and sociocultural taxonomies, according to Katherine Kolcaba.

This project will assess the impact of continuing nursing education on HAI prevention to improve patient comfort and safety and indulge them in positive health-seeking behaviors. This theory has been applied to various studies seeking to improve caregiver and patient health by addressing personal, structural, and human resource barriers to patient comfort and safety.

Evidence-based Change Model

Change is an inevitable and integral part of contemporary nursing practice. Quality improvement comes with transitions to newer, better practices that require change. Movement from old to new paradigms happens when certain change models are used (Harrison et al., 2021). This direct practice improvement will use the health belief model for change.

Health Belief Model This model has been in use for decades now. Health Belief Model is a change model that guides health prevention and promotion interventions to effect change. It provides an explanatory framework for research aiming at providing change and quality.

This model suggests that individuals are more likely to make changes if they perceive the susceptibility and severity of a threat and the risks (Conner & Norman, 2022). Critical constructs of this model include perceived threats, perceived benefits, cues to action, and self-efficacy. This model was put forward by Hochbaum & Rosenstock in 1952 to understand a person’s motivation for certain behavioral actions (Mckellar & Sillence, 2020).

This project hypothesizes that the achievement of nurses’ motivation for action to promote healthy strategies in HAI prevention will be determined by personal and systemic factors that they perceive as threats or benefits. Targeting these barriers and benefits is a strategy that will initiate action change to enhance quality and ensure patient safety.

Clinical Question. The change in the question revolves around the motivation that cantons patient safety educations nurses will impart to the nurses. The improvement from their baseline knowledge is presumed to be a key factor in determining behavioral change for action.

Lack of this education for nurses is assumed to be a negative force that will provide a lack of knowledge and demotivation for behavior change. This education is, therefore, a significant player in change initiation and quality improvement.

Synthesis of Evidence-based Change Model. The health belief model has been used in the nursing field and in sociology and psychology to guide change. Various studies in nursing have successfully used HBM to impart change outcomes in various organizations.

Chen et al. (2019) conducted a cross-sectional survey of nurses that found that the HBM model was effective in influencing nurses’ decisions to take immunizations and uptake of related processes. Adopting the HBM showed increased nurses’ confidence through awareness of perceived benefits, risks, and self-efficacy.

A similar study by Mo et al. (2019) found that HBM increased moral responsibility to increase influenza vaccination rates among them. A multicenter study by Kwok et al. (2019) confirmed similar results among nurses that led to collectivism and enhancement of cultural values for change through a direct negative links and indirect positive links.


The health belief model is an evidence-based change model that applies to this direct practice improvement project. It focuses on perceived barriers, benefits, self-efficacy, and cues for change actions. To nurses, these can be important motivating factors to take active patient safety roles. Enhancement of awareness is a crucial intervention to break the status quo and initiate behavioral change.

Summarized studies that have successfully applied the HBM model reported positive results with its use, especially amongst nurses regarding vaccination uptake. Borrowing this concept to patient safety is the basis of using the HBM model in this project.

Linking Nursing Theory, Change, and Model to the Direct Practice Improvement Project

Patient safety is a critical component of patient care quality. Influencing nurses to take up an active role in patient safety procedures and programs is believed to be possible through continuous patient safety education. Ensuring holistic care requires nurses to address patient safety concerns to promote health and prevent healthcare-associated infections. This could be possible through continuous safety education as part of behavioral change.

Therefore, the purpose of this quantitative quasi-experimental project was to determine to what degree the implementation of continuous safety education for nurses would impact patient safety outcomes when compared to current practice among nurses in the inpatient units in the state over four weeks.


The comfort theory by Kolcaba suggests that patient comfort is a result of ease, relief, and transcendence. Concerning HAIs, comfort will be achieved in absence of infections or symptoms of the same. For example, nurses’ intervention to prevent infections will provide physical relief to postoperative patients. This will require the active engagement of the nurses in processes to achieve the same.

The health belief model (HBM) explains that effective behavioral change is driven by perceived barriers, benefits, self-efficacy, and cues to action. This will be applicable in this project because continuous safety education to nurses is expected to act as a motivator to improve nursing awareness and confidence to participate in patient safety improvement strategies in the inpatient units.

Therefore, HBM complements the comfort theory in effecting the necessary change to achieve patient comfort and holistic care because it provides the modifying factors for change (Mckellar & Sillence, 2020). The theory provides the necessary framework to guide the elements of holistic care that include patient safety awareness. This interdependence is helpful to my direct practice improvement project because it links my PICOT intervention to comparison interventions and outcomes.


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