Digital Repository Masters Theses Spring 2026 Improving Adherence to Dysphagia Screening in Acute Stroke Patients by Registered Nurses Faith Allen Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Allen, F. 2026. Improving Adherence to Dysphagia Screening in Acute Stroke Patients by Registered Nurses. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Improving Adherence to Dysphagia Screening in Acute Stroke Patients by Registered Nurses Project Title by Faith Allen Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY April 2026 Ogden, UT Date 04.14.2026 Student Name, Credentials (electronic signature) Date 5/28/26 MSN Project Faculty (electronic signature) Date 6/9/26 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Improving Adherence to Dysphagia Screening in Acute Stroke Patients by Registered Nurses Faith Allen Annie Taylor Dee School of Nursing Weber State University Dr. Amber Fowler MSN Project April 14, 2026 2 Abstract Purposes/Aims: This quality improvement project aimed to improve registered nurse (RN) adherence to dysphagia screening prior to oral intake from 56% to 85% over three months in adult patients with acute stroke. Rationale/Background: Post-stroke dysphagia increases the risk of aspiration pneumonia, mortality, prolonged hospitalization, and healthcare costs. Although national guidelines require screening before oral intake, local data revealed compliance rates below the 85% American Heart Association benchmark, indicating workflow and practice gaps identified from chart reviews and nurse interviews. Methods: Guided by Kotter’s 8-Step Change Model, a framework for creating lasting organizational change, multifaceted interventions were designed that included implementing an electronic health record (EHR) prompt, targeted stroke unit RN education, and leadership reinforcement. Educational materials and pre- and post-surveys were developed to assess knowledge and confidence. Compliance with dysphagia screening completion was evaluated using national stroke quality metrics. Results: Literature supports three key strategies for improving adherence: competency-based education, EHR clinical decision support prompts, and strong leadership engagement to sustain change. Conclusions: Integrating education, technology, and leadership support into nursing workflow has the potential to improve dysphagia screening compliance, enhance patient safety, and strengthen stroke program performance. Sustained adherence advances evidence-based nursing practice and promotes safer stroke care. Keywords: dysphagia screening, acute stroke, nurse compliance, EHR prompts, patient safety 3 Improving Adherence to Dysphagia Screening in Acute Stroke Patients by Registered Nurses Stroke is the fifth leading cause of death and the number one leading cause of disability for adults in the United States (American Stroke Association, n.d.). Dysphagia, an impairment in swallowing that results in abnormal transit of liquids or solids to the stomach, is a common complication affecting patients post-stroke and leads to morbidities like pulmonary complications, malnutrition, dehydration, and prolonged hospitalization (Azer et al., 2023; Khedr et. al., 2021). To protect patients from unnecessary morbidities or mortality, early identification of dysphagia symptoms is vital, and screening patients for dysphagia must be a priority for the care team. To address this gap, this project aims to improve registered nurse adherence to dysphagia screening by (a) implementing an EHR update that prompts nurses when a screening is required, (b) providing ongoing education on dysphagia screening and proper screening techniques, and (c) streamlining the nursing workflow to support timely completion of screenings. The goal is to determine whether integrating this evidence-based intervention enhances compliance with dysphagia screening before oral intake in stroke patients over three months. Statement of Problem Chart reviews and data abstraction conducted through a local stroke program in Ogden, UT, identified low compliance with bedside dysphagia screenings prior to oral intake among acute stroke patients (A. Briggs, M. Davis, & T. Howell, personal communication, May 15, 2025). The data from the first quarter of 2025 indicated a 56% compliance rate, well below the hospital’s best-practice benchmark of 85% set by the American Heart Association’s Get With the Guidelines program. This concern was raised during the division stroke coordinator meeting, 4 which included representatives from 11 division hospitals and quality directors, and revealed that dysphagia screening compliance was an area for improvement across all facilities. This shortcoming was identified using the American Heart Association’s Get With The Guidelines online data abstraction program, which enables reports to be generated on specific metrics, including compliance with dysphagia screening prior to oral intake. The data showed that our hospital’s compliance rate was 56% for April 2025 and 76% across August 2024–August 2025, both falling short of the 85% national benchmark, highlighting a clear need for improvement. Early identification and screening of swallowing difficulties in acute stroke patients is considered best practice and reduces the likelihood of harm to patients, but there is a gap in clinical implementation (Sherman et al., 2021). Current practice is often inconsistent due to time constraints, lack of registered nurse (RN) education, and poor workflow integration. This inconsistency, however, can be detrimental since swallowing abnormalities lead to a three-fold higher mortality rate in the post-stroke patient (Donovan et. al., 2013). This project aims to improve RN adherence to dysphagia screening protocols, thereby reducing complications such as aspiration pneumonia and prolonged hospitalizations secondary to choking or malnutrition. By aligning nursing practice with national stroke guidelines, the initiative will not only benefit patients through safer care but also empower nurses with greater confidence and competency, thereby supporting overall patient outcomes and reducing medical costs for the hospital. Providing appropriate dysphagia screenings can reduce hospital costs by preventing costly complications like aspiration pneumonia, which lowers rates of pneumonia and shortens length of stay, and by reducing overall inpatient costs per admission among patients with dysphagia (Langmore et al., 2019). Overall, RN compliance with the post-stroke dysphagia screening will strengthen hospital stroke programs by improving performance on national benchmarks. 5 Significance of the Project This project is significant as it will address a critical patient safety issue, fill gaps in current nursing practice, and support organizational priorities. Patient safety is the most significant, and it has been reported that when a dysphagia screening protocol is in place, morbidity decreases year over year (Daniels et al., 2013). However, if the current protocol does not adequately support registered nurses in completing a bedside swallow study, the process must be updated. Best-practice interventions, such as training, audits, and electronic health record (EHR) prompts, may increase adherence. EHR prompts are shown to improve risk management by providing clinical alerts and enabling evidence-based decision-making at the exact moment of care (Office of the National Coordinator for Health Information Technology, n.d.). Creating protocols and EHR prompts that alert a nurse when a dysphagia screening is due is best practice, aligning with national guidelines and improving quality metrics and hospital accreditation outcomes. Stroke-related dysphagia is a significant safety issue, and inconsistent RN adherence to screening protocols increases patient risk. This project will address the practice gap by implementing evidence-based strategies to improve screening adherence and patient outcomes. Review of the Literature This literature review aims to explore current evidence regarding strategies to improve nurse adherence to dysphagia screening protocols in acute stroke care. Early identification of swallowing difficulties is essential to prevent aspiration pneumonia and improve patient outcomes, yet compliance with RN-performed screenings before oral intake remains inconsistent. The literature revealed three primary themes related to this issue: (1) the impact of education and competency training on nurse performance, (2) the role of electronic health record 6 (EHR) prompts and clinical decision support tools in improving screening compliance, and (3) the influence of interprofessional communication and leadership engagement on sustaining practice change. These themes align with the project’s PICOT question: In registered nurses working with acute stroke patients, how do best practices or strategies, compared with current practice, affect adherence to RN-level dysphagia screening before oral intake within 3 months of implementation? Framework The guiding framework for this project is Kotter’s 8-Step Change Model. Developed by John Kotter, this model provides a structured approach to organizational change and improvement. The model’s eight steps include creating urgency, building a guiding coalition, developing and communicating a vision, empowering employees, generating short-term wins, consolidating gains, and anchoring new approaches into the culture (Kotter, n.d.). This framework is practical in healthcare settings because change initiatives require both leadership support and staff engagement, and this model supports those needs (Hussain et al., 2018). For this project, which aims to improve compliance with bedside dysphagia screenings in acute stroke patients through an EHR prompt, Kotter’s model aligns well with each phase of implementation. The first step, creating a sense of urgency, involves sharing data that shows low compliance rates and emphasizing the impact on patient safety. Building a guiding coalition will involve key stakeholders, including health informatics leaders, nursing leadership, hospital executives, the director of quality, and the stroke coordinator. Forming a strategic vision will focus on integrating an EHR alert to standardize the nurses’ workflow. The EHR alert would be a real-time notification that appears when a nurse opens the patient’s chart, indicating: “Dysphagia screening required: complete before administering oral medications, food, or fluids.” 7 Communicating the vision will be achieved through staff education and huddle updates. Empowering action involves leaders removing barriers, such as barriers to documentation or a lack of understanding of the dysphagia screening. Generating short-term wins will be achieved by celebrating improvements in compliance rates of documented dysphagia screenings and positive patient outcomes. Some examples of showcasing positive outcomes include nursing scoreboards on unit communication boards and stroke pins and recognition points for nurses with the highest compliance rates each quarter. Consolidating gains will involve refining processes based on staff feedback, and anchoring the change will ensure that dysphagia screening compliance becomes a sustained part of stroke care in the hospital. Strengths and Limitations A strength of Kotter's 8-Step model is its emphasis on leader engagement and clear communication, both of which are essential for implementing change in the healthcare environment (Appelbaum et al., 2012). The model provides a step-by-step approach that promotes stakeholder buy-in and accountability. However, a key limitation is that Kotter's model assumes linear progression, which may not represent the ever-changing healthcare landscape. Additionally, the model can be time-intensive, which can be challenging to sustain as other projects and needs can blur the sense of urgency created for the project at hand. The final limitation is that the model does not address frontline staff resistance to new implementation. Despite these limitations, Kotter's framework remains a strong choice, offering a clear roadmap for sustainable behavior change in clinical practice. Kotter’s model can be used in large-scale cultural change and leave a lasting impact throughout an organization. 8 Search Strategies A comprehensive literature search was conducted to identify current evidence on strategies that improve nurse adherence to dysphagia screening in acute stroke patients. The search focused on best practices, use of electronic health record (EHR) prompts, and leadership engagement to enhance compliance with RN-level dysphagia screenings before oral intake. The following databases were used: CINAHL Complete, PubMed, Google Scholar, and Weber State University’s Stewart Library OneSearch and Advanced Search. The search included the following keywords and Boolean combinations: (“dysphagia” OR “swallow study”) AND (“acute stroke”) AND (“EHR prompts” OR “EHR prompts for nurse charting”) AND (“nurse compliance” OR “dysphagia screenings”) AND (“leadership influence on charting” OR “stroke patient safety” OR “swallow disorders”). Filters were applied to limit results to English-language articles and studies conducted in adult hospital settings. Reference lists of key studies and systematic reviews were also scanned to identify additional relevant sources. This process ensured a comprehensive, replicable search strategy that captures the current evidence on improving adherence to dysphagia screening protocols in acute stroke care. Synthesis of the Literature A review of current literature identified recurring themes aimed at improving nursing completion and documentation of dysphagia screening in acute stroke care. Three major themes emerged from the synthesis: the impact of education and competency training on nurses’ adherence to screening procedures; the effectiveness of electronic health record (EHR) prompts and clinical decision support tools in improving documentation; and the importance of leadership engagement and interprofessional communication in sustaining practice change. Together, these themes highlight the complex strategies needed to enhance screening consistency, ensure patient 9 safety, and promote evidence-based stroke care within the acute setting. The gaps in the literature included a lack of information on RN workflow alignment and RN resistance to charting dysphagia screenings prior to oral intake. Impact of Competency Training The literature consistently identifies education and competency training as key strategies to improve nurses' adherence to dysphagia screening protocols in acute stroke care. Ongoing education that emphasizes both proper documentation and the importance of dysphagia screenings—including recognizing patient signs and symptoms or risk factors—enhances nurses’ knowledge of stroke-related dysphagia, boosts confidence in performing screenings, and supports timely identification of swallowing difficulties. For example, Bray et al. (2017) found that targeted education and feedback interventions significantly improved compliance with dysphagia screening within the first 24 hours of stroke admission. Similarly, Smithard (2016) reported that structured stroke education programs led to greater consistency in nurse-led screening and reduced rates of aspiration pneumonia. Training initiatives that include simulation or competency validation also demonstrate improved retention and performance outcomes, particularly when reinforced with real-time feedback (Hines et al., 2016). Furthermore, regular in-service education supported by clinical leadership fosters a culture of accountability and evidence-based practice (Zhang et al., 2022). Collectively, these studies demonstrate that comprehensive education and competency programs are essential to ensure consistent adherence to dysphagia screening standards and improve patient safety in stroke care. However, there was little discussion of the ongoing reinforcement needed to sustain the changes. 10 The Role of Electronic Health Record Prompts The integration of electronic health record (EHR) prompts and clinical decision support tools (CDS) has been shown to significantly enhance nurse compliance with evidence-based screening and documentation practices, including dysphagia screening in stroke care (Lytle et al., 2015). Automated reminders help bridge gaps between knowledge and action by prompting nurses to complete critical assessments at the appropriate time. A QI study by Lakshminarayan et al. (2012) reports that embedding a CDS tool in the EMR increased completion of dysphagia screenings prior to oral intake and improved the reliability of RN documentation. Similarly, Torab-Miandoab et al. (2020) developed and evaluated an intelligent electronic health record (EHR)– based system designed to enhance adherence to clinical guidelines for acute stroke management. The study found that automated EHR prompts and decision support tools enhanced the timeliness and accuracy of stroke assessments, including dysphagia screenings, by reminding clinicians to complete critical interventions in alignment with best practices. Studies also indicate that CDS tools facilitate timely decision-making and reduce cognitive workload by standardizing the screening process (Middleton et al., 2016). Furthermore, when integrated with education and feedback mechanisms, EHR interventions sustain long-term improvements in care quality and patient safety (Kruse et al., 2020). Overall, the literature supports the effectiveness of EHR prompts and CDS tools as data-driven methods for improving adherence to dysphagia screening protocols and enhancing the reliability of stroke care documentation. In practice, such tools can provide nurses with pop-up reminders within the EHR when a dysphagia screening has been ordered, prompting timely charting and ensuring that dysphagia screenings are consistently documented. 11 The Influence of Leader Engagement Interprofessional communication and leadership engagement are cited as critical factors in sustaining practice change. Studies show that when nurse leaders actively support evidencebased initiatives, provide feedback, and model expected behaviors, staff are more likely to adopt and maintain new practices (Gershon et al., 2018). Effective communication across disciplines facilitates the timely identification of patients at risk for dysphagia and ensures coordinated care (Chen et al., 2024). Moreover, embedding change within organizational culture through leadership advocacy and team collaboration helps to normalize adherence to protocols, making improvements durable over time (Damschroder et al., 2022). By modeling best practices, addressing barriers promptly, and celebrating staff successes, leaders create an environment that encourages consistent use of the tool and sustained quality improvement. Leaders who discuss the importance of early dysphagia screening with their staff and listen to understand the barriers will create an environment where quality becomes increasingly important. Summary of Literature Review Findings and Application to the Project The literature review identified three key themes that influence adherence to RN-level dysphagia screening in acute stroke care. Evidence consistently shows that targeted education and competency programs improve nurses’ knowledge and compliance with screening protocols. EHR-based reminders and decision support tools enhance adherence by embedding prompts into the workflow, reducing missed screenings, conducting leadership audits on compliance, and supporting timely care. Finally, sustained practice change relies on strong leadership support and effective communication among healthcare professionals, which reinforces accountability and integrates best practices into the organizational culture. 12 Applying these findings to the proposed project, the interdisciplinary team will implement a multidimensional approach to improve compliance with dysphagia screening. Nurse education sessions will ensure staff are competent and confident in performing screenings. An EHR prompt will serve as a real-time reminder to complete screenings before oral intake. Leadership engagement and interprofessional communication strategies will further reinforce adherence, creating a supportive environment for sustainable change. Together, these evidencebased strategies directly address barriers identified in the literature and provide a strong foundation for achieving measurable improvements in patient safety and quality of care. Project Plan and Implementation This section outlines the proposed plan for change and the process for implementing an evidence-based intervention aimed at improving registered nurse adherence to dysphagia screening prior to oral intake in acute stroke patients. Guided by findings from the literature review and informed by local data, the project plan focuses on integrating an electronic health record prompt, providing targeted RN education, and strengthening interdisciplinary collaboration to support consistent screening practices. Although the project will not be implemented during the MSN program due to a lack of funding and timing constraints, this section describes how the intervention would be operationalized in the clinical setting, identifies key stakeholders, and details the roles of the interdisciplinary team involved in supporting and sustaining the proposed change. Plan and Implementation Process The proposed project will be implemented within an acute care hospital that provides emergency and inpatient stroke services, is accredited by DNV as a Primary Plus Stroke Center, and participates in the American Heart Association’s Get With The Guidelines Stroke program. 13 The primary setting for implementation will be the emergency department, intermediate care unit, and critical care unit that routinely admit and care for acute ischemic and hemorrhagic stroke patients. The target population includes adult stroke patients, while the primary recipients of the intervention will be registered nurses responsible for initial patient assessments, medication administration, and documentation of dysphagia screening prior to oral intake. The implementation plan will follow a structured approach aligned with Kotter’s 8-Step Change Model. The first phase will create urgency by presenting current compliance data to nursing leadership, stroke governance committee members, and frontline nursing staff. Sharing local performance metrics that show dysphagia screening rates below national benchmarks and that could result in the loss of DNV accreditation will underscore the patient-safety implications of missed or delayed screenings and build support for change. Next, the project team will establish a guiding coalition comprising the stroke program coordinator, nursing leadership, quality improvement representatives, informatics specialists, speech-language pathologists, and physician champions. This coalition will oversee project planning, address barriers, and ensure alignment with organizational priorities. Together, the team will develop a clear vision for improving dysphagia screening adherence by embedding a standardized EHR prompt into the nursing workflow, supported by education and leadership reinforcement. The EHR intervention will consist of a clinical decision support prompt that appears when a nurse opens the chart of a patient admitted with a suspected or confirmed stroke diagnosis, identified by the physician’s use of a previously built stroke order set. The prompt will clearly indicate that a dysphagia screening is required before administering oral medications, food, or fluids, and will link directly to the appropriate documentation flowsheet. Collaboration 14 with the health informatics team will be essential to ensure the alert is concise, clinically relevant, and minimally disruptive to workflow. Before going live, the project team will test the alert in a non-production environment to confirm its functionality. Concurrent with the EHR update, the education team will develop and deliver an education plan to nursing staff. Education will include a review of stroke-related dysphagia, the rationale for early screening, proper use of the approved RN-level dysphagia screening tool, and documentation expectations within the EHR. Education sessions will be delivered through multiple modalities, including brief in-person huddles, recorded modules, and written tip sheets embedded within the EHR. Competency validation, which is an assessment of a nurse’s ability to perform a skill or task, may be incorporated to ensure nurses feel confident and prepared to complete screenings accurately. Howanitz et al. (2000) describe competency in four levels: what an individual knows, measured by general knowledge; what an individual knows how to do, measured by competence; how an individual shows, measured by performance; and what an individual does, measured by action. The education team would define the four levels of competency for this skill and assess nurses against that definition. Once implemented, leadership will support the change by reinforcing expectations during shift huddles, providing real-time feedback, and addressing barriers identified by staff. Compliance data will be monitored using Get With The Guidelines reports and internal chart audits, activities that are already routinely completed by the stroke program coordinator as part of existing role responsibilities; therefore, this monitoring process will not add to the coordinator’s workload or require additional staffing resources. Early improvements in screening rates will be shared with staff as short-term wins to maintain engagement and momentum. Over time, feedback from nurses and interdisciplinary partners will be used to refine the workflow and 15 optimize sustainability, with the ultimate goal of embedding dysphagia screening adherence into standard stroke care practice. Interdisciplinary Team Successful implementation of this project will rely on collaboration among an interdisciplinary healthcare team. Each team member will play a distinct yet interconnected role in supporting the intervention. Registered Nurses Registered nurses will serve as the primary drivers of the project, as they are responsible for performing and documenting dysphagia screenings prior to oral intake in acute stroke patients. Nurses will complete education on stroke-related dysphagia, utilize the EHR prompt as a reminder to complete screenings, and document results accurately. Their engagement and feedback will be essential for identifying workflow challenges and ensuring the screening process is practical and sustainable within the fast-paced acute care environment. Stroke Program Coordinator The stroke program coordinator will lead oversight and coordination of the project. This role will include reviewing compliance data, facilitating communication between departments, supporting education efforts, and monitoring outcomes through Get With The Guidelines reporting. The stroke coordinator will also serve as a liaison between frontline staff and leadership, ensuring that concerns are addressed promptly and that progress toward benchmarks is tracked and shared. Nursing Leadership Nurse managers and clinical leaders will play a crucial role in reinforcing expectations and supporting staff throughout the implementation process. Nursing leadership will promote 16 adherence to the dysphagia screening protocol through consistent unit-based communication, real-time performance feedback, and structured accountability processes. Nurse leaders will reinforce expectations during staff meetings, huddles, and onboarding, emphasizing the patientsafety implications of timely, accurate dysphagia screening. Compliance data will be transparently shared at the unit level, allowing leaders to recognize high performance and promptly address gaps. When missed or incorrectly documented screenings are identified, nurse leaders will provide immediate coaching and, when necessary, initiate corrective action plans to ensure sustained adherence to the protocol. By modeling engagement and prioritizing patient safety, nurse leaders will help normalize the practice change and integrate it into daily nursing routines. Health Informatics and Information Technology Specialists Health informatics and IT specialists will collaborate with clinical leaders to design, build, test, and maintain the EHR prompt. Their role will be to ensure the alert aligns with clinical workflows, functions reliably, and supports accurate documentation without contributing to alert fatigue. Ongoing collaboration will allow the tool to be refined based on user feedback and performance data. Speech-Language Pathologists Speech-language pathologists (SLPs) will provide subject-matter expertise in dysphagia assessment and management. They will support nurse education by clarifying screening criteria, reinforcing appropriate referral processes, and collaborating on care plans for patients who fail initial screenings. Interdisciplinary communication between nursing and SLPs will help ensure timely evaluations and continuity of care for patients with swallowing impairments. 17 Physicians and Advanced Practice Providers Physicians and advanced practice providers will support the project by reinforcing the importance of dysphagia screening within the stroke care pathway and by consistently utilizing the standardized, evidence-based stroke order sets developed and approved by the medical executive committee prior to this initiative. Their engagement will promote interdisciplinary accountability and ensure that orders, diet advancement, and medication administration align with documented screening results embedded within the order sets. By modeling best practices in order entry and clinical decision-making, providers will help normalize protocol-driven care. Physician champions may also advocate for the project at the organizational level, strengthening long-term sustainability and system-wide adoption. Monthly scorecards will be sent to physicians by the stroke program coordinator regarding the use of the order set. The stroke program coordinator will obtain compliance data of order set usage from the Health Information Management team, and this information will be disseminated by the stroke program medical director. Quality Improvement and Patient Safety Team Quality improvement professionals will assist with data analysis, performance monitoring, and reporting of outcomes related to dysphagia screening compliance. Their expertise will support the evaluation of the intervention’s effectiveness and alignment with regulatory and accreditation standards. Collaboration with the quality team will ensure that improvements are measurable and tied to organizational patient safety goals. Through coordinated teamwork and shared accountability, the interdisciplinary team will support the successful implementation of the proposed project. By aligning clinical practice, 18 technology, education, and leadership engagement, the initiative aims to improve RN adherence to dysphagia screening, therefore enhancing the overall quality of stroke care. Description and Development of Project Deliverables Project Deliverables and Materials This project includes three primary deliverables designed to support registered nurse (RN) adherence to dysphagia screening prior to oral intake in acute stroke patients. These deliverables include an educational PowerPoint presentation, a unit-based educational flyer, and a pre- and post-education Microsoft Forms survey. Each deliverable is individually important as they educate in different styles for different learners, and align with evidence identified in the literature review and support knowledge acquisition, workflow reinforcement, and outcome evaluation. Educational PowerPoint for Registered Nurses The first project deliverable is a PowerPoint presentation developed to educate registered nurses on stroke-related dysphagia and the importance of completing a dysphagia screening prior to oral intake (see Appendix A). The presentation provides foundational knowledge on dysphagia, including definitions, prevalence in acute stroke patients, associated risks such as aspiration pneumonia, and the rationale for early screening. The PowerPoint will be primarily owned and updated by the critical care educator, with input from the stroke program coordinator. Content also reviews the approved RN-level dysphagia screening tool, step-by-step screening procedures, documentation expectations, and required actions following a failed screen. This PowerPoint will be used during nurse education sessions delivered through multiple modalities, including unit-based huddles, staff meetings, and review via the learning management system. Staff will be signed off in their HealthStream accounts once they have 19 completed the education. The flexible format allows education to be integrated into existing workflows and accommodates varying shift schedules. The presentation also serves as a standardized reference to ensure consistent messaging across departments caring for stroke patients. The use of a formal educational presentation is strongly supported by the literature. Multiple studies demonstrate that targeted education improves nurse knowledge, confidence, and adherence to dysphagia screening protocols (Bray et al., 2017; Smithard, 2016). Education that clearly links screening practices to patient safety outcomes has been shown to reduce missed screenings and lower rates of stroke-associated pneumonia (Daniels et al., 2013). By reinforcing evidence-based rationale and clearly outlining expectations, this deliverable directly addresses knowledge gaps identified in the literature and supports sustained practice change. Unit-Based Dysphagia Screening Flyer The second deliverable is a one-page educational flyer designed for display in staff breakrooms and nursing work areas (see Appendix B). The flyer provides a concise visual reminder of key dysphagia screening principles, the requirement to complete screening prior to oral intake, and quick-reference steps for documentation and escalation when a patient fails a screen. This flyer will serve as a cognitive aid to reinforce learning after the formal teaching session concludes. Its purpose is to support real-time decision-making and reduce reliance on memory alone during busy clinical shifts. Visual reinforcement materials are especially valuable in high-acuity environments, where competing demands can lead to missed steps in care delivery. 20 The literature supports the use of visual reminders and point-of-care educational tools to reinforce evidence-based practices. Studies show that combining education with visual cues enhances retention and improves adherence to clinical protocols (Zhang et al., 2022). Additionally, workflow-integrated reminders reduce cognitive burden and promote consistency in care delivery (Middleton et al., 2016). This flyer complements the PowerPoint education by providing ongoing reinforcement and supporting sustained adherence to dysphagia screening expectations. Pre- and Post-Education Nurse Survey The third deliverable is a Microsoft Forms survey administered to nurses before and after the dysphagia education intervention (see Appendix C). The survey is designed to evaluate changes in nurse knowledge, confidence, and perceived importance of dysphagia screening. Questions include self-assessment of familiarity with dysphagia screening protocols, confidence in performing the screening, and perceived barriers to compliance. The pre-education survey will establish a baseline understanding of nurses’ knowledge and attitudes related to dysphagia screening, while the post-education survey will assess the perceived effectiveness of the educational intervention. Survey results will be used to identify areas for improvement, guide future education, and support evaluation of the project’s impact on nursing practice. The results will be accessible by the implementation team, and the survey will be updated by the stroke program coordinator, who will report findings to the Director of Quality for any necessary information dissemination to unit leadership. Evaluation methods such as pre- and post-intervention surveys are supported in the literature as effective tools for measuring educational outcomes and practice readiness (Hines et al., 2011). Assessing perceived confidence and knowledge is particularly important when 21 implementing practice changes that rely on nurse judgment and skill performance. When combined with objective compliance data, survey findings help provide a comprehensive evaluation of intervention effectiveness (Kruse & Ehrbar, 2020). This deliverable supports datadriven decision-making and continuous quality improvement. Timeline The implementation of this practice change project will unfold over a six-week period following approval from organizational leadership and relevant stakeholders. The timeline follows a logical progression from preparation and development through education delivery and evaluation of outcomes. Key phases include planning and stakeholder communication, development of materials, pilot rollout of education, administration of pre- and post-intervention surveys, and evaluation of compliance and feedback. The first week will focus on finalizing project materials, including the PowerPoint presentation (Appendix A), educational flyer (Appendix B), and Microsoft Forms survey (Appendix C). During this phase, the project lead will consult with nursing education leadership and inform unit managers about the upcoming initiative. Weeks two and three will be dedicated to educational deployment, with multiple education sessions scheduled across all shifts to ensure maximal nurse participation. Concurrently, staff will be asked to complete the pre-education survey prior to attending an education session. In week four, visual reinforcement materials (flyers) will be distributed and placed in high-visibility areas on each unit. Weeks five and six will be reserved for post-education survey administration, nurse feedback collection, and preliminary evaluation of dysphagia screening compliance rates. Throughout the implementation period, the project lead will monitor participation, address emerging barriers, and adjust scheduling or communication as needed to 22 support engagement. The team members will repeat education over several weeks, spanning multiple shifts, including nights and weekends. A visual timeline graphic illustrating these phases and corresponding weeks is provided in the Appendix (see Appendix D). The graphic uses a horizontal Gantt-style format to map each activity against target weeks, enabling clear visualization of dependencies and milestones. This project will systematically improve nurse knowledge and compliance with dysphagia screening through education, reinforcement, and evaluation over a six-week period. By aligning preparation, education delivery, and evaluation within a structured timeline, the plan supports sustained practice change and measurable outcomes. The audits will begin four weeks after implementation and continue for one year. If results improve and remain stable for eight weeks, it will be considered sustainable. Project Evaluation The effectiveness of this quality improvement project will be evaluated using both formative and summative evaluation methods to determine whether the proposed interventions improve registered nurse adherence to dysphagia screening prior to oral intake in patients with acute stroke. A mixed-methods evaluation approach is appropriate for quality improvement initiatives because it enables continuous monitoring of implementation processes and measurement of outcomes after the intervention period. This dual approach supports timely identification of barriers and facilitates data-driven refinement of practice changes (Huston, 2024; Melnyk & Fineout-Overholt, 2023). Formative evaluation will occur throughout the implementation period to assess progress and identify barriers in real time. One formative strategy will include monitoring participation in nursing education sessions and completion rates of the pre-education survey. Participation in the 23 education sessions will be expected for all registered nurses who care for stroke patients, delivered through brief unit-based in-services and an electronic module to ensure accessibility across shifts. Attendance will be tracked through sign-in sheets for in-person sessions and by completing reports from the learning management system for the electronic module. Nurses who are unable to attend the scheduled sessions will be required to complete the online module during the implementation period to ensure consistent exposure to the educational content. Tracking attendance and survey completion will help determine whether the selected educational delivery strategies effectively reach nursing staff across shifts and units. Ongoing staff engagement is a critical component of successful practice change and sustainability in clinical quality improvement (Melnyk & Fineout-Overholt, 2023). Additional formative feedback will be obtained informally from registered nurses, nurse leaders, and interdisciplinary team members during staff huddles and unit meetings. Feedback will focus on the usability of the electronic health record (EHR) prompt, the clarity of educational materials, and the perceived workflow impact. Concerns related to alert fatigue, documentation burden, or role ambiguity will be addressed collaboratively with nursing leadership and informatics specialists, consistent with recommended implementation science practices that emphasize stakeholder engagement and rapid-cycle improvement (Huston, 2024). Early compliance trends identified through Get With The Guidelines–Stroke reports and internal chart reviews, both of which are current job tasks for the stroke program coordinator, will provide supplementary formative data, enabling early recognition of improvement opportunities before full summative analysis. Summative evaluation will assess the overall effectiveness of the intervention following implementation. The primary outcome measure will be registered nurse adherence to dysphagia 24 screening prior to oral intake in patients with acute stroke. Compliance rates will be evaluated by comparing 6 months of pre-implementation and 6 months of post-implementation data extracted from the American Heart Association Get With The Guidelines–Stroke database and routine internal chart audits conducted by the stroke program coordinator. The use of standardized national quality metrics, for example, every stroke patient that received a dysphagia screening prior to oral intake as the numerator and every stroke patient as the denominator, enhances the reliability and clinical relevance of outcome evaluation in stroke care improvement initiatives (American Heart Association, 2023). Secondary outcome measures will include changes in nurses’ knowledge and confidence regarding dysphagia screening, measured through pre- and post-education surveys administered via Microsoft Forms. Likert-scale responses will be analyzed to evaluate changes in self-reported understanding of the importance of dysphagia screening, confidence in performing the nurselevel screening tool, and knowledge of documentation and escalation procedures. Although these surveys are not validated research instruments, several steps were taken to enhance their usefulness as measurement tools. Survey questions were developed to align directly with the intervention's educational objectives and key competencies related to dysphagia screening in acute stroke care. To strengthen content validity, the survey items were reviewed by clinical experts, including stroke program leadership and experienced bedside nurses, to ensure clarity and alignment with current stroke care practices. The survey was also designed using consistent Likert-scale response options to allow for comparison of pre- and post-intervention responses. While primarily intended for internal quality improvement evaluation, the survey provides meaningful insight into educational effectiveness and staff readiness to implement the dysphagia screening process (Melnyk & Fineout-Overholt, 2023). 25 When available, additional summative indicators will include rates of documented screening completion prior to oral medication administration or diet advancement, as well as referral rates to speech-language pathology following failed screenings. These outcome measures help determine whether improved screening adherence translates into appropriate downstream clinical actions and enhanced patient safety, specifically the rate of patients diagnosed with aspiration pneumonia while in the hospital. Findings from the summative evaluation will be disseminated to nursing leadership, the stroke governance committee, and frontline clinical staff. Results will inform decisions regarding sustainability, spread to additional units, and future quality improvement priorities, consistent with best practices for organizational learning and continuous performance improvement (Huston, 2024). Ethical Considerations Ethical considerations are integral to this quality improvement project and will be addressed to ensure respect for participant privacy, equitable treatment of staff, and responsible stewardship of data. The project demonstrates social responsibility by prioritizing patient safety and reducing preventable harm associated with missed or delayed dysphagia screening in acute stroke, aligning with national stroke care quality and patient safety standards (American Heart Association, 2023). No patient-specific information will be shared, and all information is part of the medical record. Participation in project-related surveys will be voluntary and lack of participation cannot be used punitively against employees. Registered nurses who decline to participate in the survey will not face negative consequences, and their decision will not affect employment status, performance evaluations, or professional relationships. Surveys will be stored on the secure 26 online drive, accessible only with specific account permissions. The surveys will be kept in accordance with the hospital’s data retention policy. Educational content on dysphagia screening expectations will be delivered as part of routine patient safety education and organizational practice standards, consistent with accreditation and regulatory expectations for stroke care. Confidentiality and privacy will be maintained throughout the project. Survey responses will be collected anonymously to encourage honest feedback from nursing staff and to reduce concerns that responses could influence performance evaluation or employment status. The Microsoft Forms survey will be configured to disable name collection and will not record email addresses or other identifying information. Participants will not be asked to provide identifying details beyond their assigned working unit, ensuring responses cannot be linked to individual nurses. Overall, RN education is a mandatory requirement for employment, while completing the survey is not. Compliance data obtained through Get With The Guidelines–Stroke reports, which only include compliance data and do not link to patient identifiers or RNs involved in care, and internal chart audits will be aggregated at the unit level to prevent identification of individual nurses. All project data will be stored on the organization’s secure, password-protected network drive in accordance with institutional quality-improvement and patient-privacy policies. Access to the data will be restricted to the project lead and approved stakeholders directly involved in the quality improvement initiative, such as stroke program leadership or the clinical educator supporting the project. Files will not be stored on personal devices, and access permissions within the network drive will be limited to authorized users only. These safeguards align with ethical principles of beneficence, nonmaleficence, and respect for persons in healthcare quality improvement activities (Melnyk & Fineout-Overholt, 2023). 27 Equity and non-discrimination will also be emphasized. All units and shifts caring for stroke patients will receive equal access to education and resources. There will be no educational disadvantage for night shift or PRN employees. Educational materials will be designed to accommodate diverse learning styles, clinical experience levels, and professional backgrounds, promoting inclusive participation and successful competency development. Recognition of potential bias is another ethical priority. Because the stroke program coordinator monitors compliance data, there is potential for interpretive bias. To mitigate this risk, objective standardized data sources, structured surveys, and collaborative review with nursing leadership and quality improvement professionals will be used. Transparent data interpretation and shared governance oversight support ethical accountability, professional integrity, and the delivery of safe, evidence-based patient care (Huston, 2024). Discussion This discussion summarizes the dissemination plan, the project's significance to advancing nursing practice, the implications of implementation, and recommendations for future improvement and research. Improving registered nurse (RN) adherence to dysphagia screening prior to oral intake in acute stroke patients is an evidence-based strategy supported by the literature to reduce the risk of aspiration pneumonia, decrease mortality, and enhance patient safety (American Stroke Association, n.d.). The proposed multifaceted intervention aligns with national stroke guidelines set forth by the AHA, Joint Commission, and DNV, and quality improvement priorities. Disseminating project findings through academic, organizational, and professional channels will promote knowledge translation, while evaluation of strengths, limitations, and future recommendations will support sustainability and potential replication in other healthcare settings. 28 Evidence-Based Solutions for Dissemination Dissemination of project findings is essential to ensure that the knowledge gained through this initiative contributes to broader nursing practice and improvements in stroke care. As part of program requirements, findings will be presented in poster format during NRSG 6802 to peers and faculty. The poster presentation will include background, problem significance, literature synthesis, intervention design, evaluation outcomes, and implications for practice. Poster dissemination supports scholarly dialogue and peer feedback while promoting professional accountability in evidence-based practice (Melnyk & Fineout-Overholt, 2023). At the organizational level, results will be shared with nursing leadership of ER, ICU, IR, and the Intermediate Care Unit, the stroke governance committee, and frontline nursing staff through formal presentations and staff meetings. This information will further funnel up through the Medical Executive Committee and the hospital’s board of regents. Unit-level compliance data, survey findings, and workflow feedback will be communicated transparently to reinforce accountability and celebrate improvements. Sharing outcomes internally aligns with principles of continuous quality improvement and organizational learning (Huston, 2024). If outcomes demonstrate measurable improvement in dysphagia screening adherence, dissemination may extend beyond the institution. Potential avenues include submitting an abstract to a regional stroke conference or publishing in a peer-reviewed nursing or strokefocused journal. National organizations such as the American Heart Association encourage the sharing of quality improvement initiatives that enhance the reliability of stroke care. Broader dissemination supports replication of successful strategies and contributes to the growing body of implementation science literature focused on translating evidence into bedside practice (Melnyk & Fineout-Overholt, 2023). 29 Significance to the Advancement of Nursing Practice This project significantly advances nursing practice by strengthening evidence-based stroke care, enhancing RN clinical accountability, and reinforcing the nurse’s critical role in patient safety. Dysphagia screening is a nurse-driven intervention that directly influences patient outcomes in the acute stroke population. When screening is delayed or omitted, patients are at increased risk of aspiration pneumonia, prolonged hospitalization, and increased mortality (Donovan et al., 2013). Evidence demonstrates that early dysphagia screening reduces pneumonia rates and improves clinical outcomes (Sherman et al., 2021). Therefore, improving adherence to RN-level screening protocols is both a patient safety imperative and a professional responsibility that supports interprofessional collaboration and care coordination. This initiative also advances nursing knowledge by integrating education, clinical decision support, and leadership engagement into a cohesive implementation strategy. Research supports that combining competency-based education with electronic health record prompts improves compliance with evidence-based interventions (Kruse & Ehrbar, 2020; Lakshminarayan et al., 2012). By operationalizing these findings in a real-world clinical environment, this project translates research into practice, which is a cornerstone of evidencebased nursing (Melnyk & Fineout-Overholt, 2023). Furthermore, the project reinforces nursing autonomy and accountability in interdisciplinary stroke care. Nurses are often the first clinicians to assess stroke patients and are responsible for administering medications and making diet advancement decisions. Strengthening adherence to dysphagia screening protocols ensures that nursing assessments directly inform safe clinical decision-making. This supports the broader professional goal of 30 positioning nurses as leaders in quality improvement and creates an opportunity for these nurses to become a trainer or champion of their units on stroke care (Huston, 2024). From an organizational perspective, improving compliance with nationally benchmarked stroke metrics enhances hospital performance and accreditation standing (The Joint Commission, 2023). Participation in the American Heart Association’s Get With The Guidelines Stroke program requires consistent documentation of dysphagia screening prior to oral intake. By improving adherence, the project aligns bedside nursing practice with national quality standards and strengthens the credibility of the institution’s stroke program. Implications Several strengths of this project support feasibility and sustainability. First, the intervention is evidence-based and supported by literature linking dysphagia screening to improved patient outcomes. Second, using an EHR prompt integrates the intervention directly into the nurse’s workflow, reducing reliance on memory and minimizing missed screenings. Third, leadership engagement and interdisciplinary collaboration enhance buy-in and accountability. Additionally, monitoring compliance through existing Get With The Guidelines reporting processes makes the project FTE-neutral and operationally feasible, as it will also allow the project to be scaled to other hospital’s within the division. Despite these strengths, potential limitations must be acknowledged. Alert fatigue may reduce the effectiveness of EHR prompts if nurses perceive them as excessive or disruptive. To mitigate this risk, collaboration with informatics specialists will ensure the alert is concise, clinically relevant, and limited to appropriate patient populations. Another limitation is reliance on self-reported survey data to measure knowledge and confidence, which may introduce 31 response bias. Pairing subjective survey findings with objective compliance data strengthens the validity of the evaluation (Melnyk & Fineout-Overholt, 2023). Competing clinical priorities and high-acuity environments may also limit consistent adherence. Addressing this barrier requires continued leadership reinforcement, visible unit-level data sharing, and ongoing education during onboarding and annual competencies. Sustainability will depend on embedding dysphagia screening expectations into routine stroke workflows and performance accountability processes. Recommendations Future recommendations focus on sustainability, expansion, and research. First, ongoing monitoring beyond the initial evaluation period is recommended to ensure sustained improvement. Quarterly compliance reviews and refresher education may help prevent regression. Incorporating dysphagia screening education into new nurse orientation and annual competency validation will further anchor the practice change within the organization’s culture. Second, future project phases could evaluate patient-centered outcomes, such as rates of aspiration pneumonia, length of stay, or cost impact associated with improved screening adherence. Future projects could also focus on the benefits of having RNs assigned as stroke champions within their units and whether having a stroke champion changes data and outcomes. While the current project primarily measures compliance, examining downstream clinical outcomes would provide stronger evidence of impact. Third, expanding the intervention to additional units that care for neurological patients, such as rehabilitation or step-down units, may improve continuity of care. Multi-site replication within the hospital division could further validate effectiveness. 32 Finally, gaps in the literature remain regarding the long-term sustainability of EHR-based prompts and the optimal balance between alerts and workflow efficiency. Future research may explore the comparative effectiveness of different clinical decision support designs or evaluate strategies to reduce alert fatigue while maintaining adherence. Conclusion This project addresses a critical patient safety gap in acute stroke care by strengthening RN adherence to dysphagia screening protocols. 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International Journal of Nursing Sciences, 9(3), 295–302. 37 Appendix A 2/1/26 DYSPHAGIA SCREENINGS FOR ACUTE STROKE PATIENTS 2026 Nursing Education DYSPHAGIA 101 • PREVALENCE: Stroke is the fifth leading cause of death and the number one leading cause of disability for adults in the United States • DEFINITION: Dysphagia is an impairment in swallowing that results in abnormal transit of liquids or solids to the stomach 1 38 39 40 41 Appendix B 42 Appendix C Microsoft Form Survey-Clickable Link Microsoft Form Survey: https://forms.gle/2aH4dDrKwXZiqD5K8 This Microsoft Forms survey was developed to assess registered nurses’ knowledge, confidence, and understanding of their role in performing dysphagia screenings for acute stroke patients. The survey includes demographic questions related to unit assignment, followed by four Likert-scale statements rated from 1 (strongly disagree) to 5 (strongly agree). Survey items evaluate nurses’ understanding of the importance of dysphagia screening, their confidence in performing the Barnes-Jewish dysphagia screening tool, their knowledge of appropriate electronic health record documentation, and their understanding of nursing responsibilities related to diet and medication administration based on screening results. The survey is administered before and after the educational intervention to evaluate changes in self-reported knowledge and confidence. 43 Appendix D