| Course | DNP 704 Principles of Evidence-based Care in Advanced Practice |
|---|---|
| Module | Module 4 |
| Paper type | Evidence-based practice final paper |
| Length | About 1,001 words, 6 pages |
| Format | APA 7 student paper |
| School | Arizona State University |
| Program | Doctor of Nursing Practice |
| Updated | October 2026 |
Free sample paper for DNP 704 Module 4
A Nurse Who Owns the Next Step: Appraisal, Synthesis and an Implementation Plan for Fracture Liaison Care
Student Name
Edson College of Nursing and Health Innovation, Arizona State University
DNP 704: Principles of Evidence-based Care in Advanced Practice
Instructor Name
Month Day, Year
A Nurse Who Owns the Next Step: Appraisal, Synthesis and an Implementation Plan for Fracture Liaison Care
Summary of Background, Question and Search
Adults with fragility fractures rarely start osteoporosis treatment; nationally, fewer than three in ten received medication within a year of hip fracture, and use declined over a decade (Solomon et al., 2014). In my orthopedic clinic, 7% of adults with fragility fractures started treatment within six months. The PICOT question asks whether a nurse-coordinated fracture liaison service, compared with usual care, increases treatment initiation within six months among adults aged 50 and older seen for fragility fracture. An exhaustive search of four databases yielded 12 sources, including three systematic reviews with meta-analyses.
Critical Appraisal
Wu et al. (2018) reviewed 57 high-quality studies and pooled randomized trials by coordinator type, finding higher bone density testing and treatment initiation with FLS. Strengths include breadth and attention to model characteristics; limitations include heterogeneity in how FLS was defined. Li et al. (2021) found lower odds of subsequent fracture with FLS care, with the clearest benefit over follow-up longer than two years; most included studies compared periods before and after FLS introduction, which risks confounding by secular trends. Danazumi et al. (2024) applied GRADE and found moderate certainty evidence of reduced secondary fracture at two years or more and low certainty at one year. Across reviews, the direction of effect is consistent, but certainty is limited by observational designs.
The national cohort by Solomon et al. (2014) is large and representative of insured patients, but claims data cannot capture reasons for nontreatment. Nonresearch sources, including the USPSTF recommendation and the knowledge-to-action framework, provide context and process guidance rather than outcome evidence.
The randomized trials give the most direct test of a coordinator role. In a trial of 220 hip fracture patients, a case manager who educated patients, ordered bone density tests and wrote prescriptions raised bisphosphonate use at six months from 22% to 51% (Majumdar et al., 2007). After wrist fracture, a lighter intervention of telephone teaching and physician reminders tripled treatment, but only from 7% to 22% (Majumdar et al., 2008). When patients still untreated a year later were randomized, a nurse case manager achieved 43% treatment against 12% for the lighter approach, at a cost of $44 per patient (Majumdar et al., 2011). The trials are small and Canadian, and the nurse in the third trial could prescribe, which my clinic's nurses cannot; the plan below routes the prescription through the primary care clinician for that reason.
Cohort studies extend the evidence to hard outcomes. Patients seen at a Dutch hospital with a liaison service had lower two-year mortality and, by 24 months, fewer subsequent nonvertebral fractures than patients at a hospital without one (Huntjens et al., 2014). An Australian comparison found about 30% fewer refractures over three years, with 20 patients managed per fracture prevented (Nakayama et al., 2015). A Swedish service run by existing secretaries raised treatment from 12.6% to 31.8% (Axelsson et al., 2016), which matters for a clinic without new funding. Because the hospitals or periods compared may differ in other ways, these studies support but cannot prove the effect.
Synthesis
The evidence supports three conclusions. First, usual care leaves a large treatment gap after fragility fracture. Second, FLS programs consistently improve testing and treatment, and longer-term studies show fewer subsequent fractures. Third, the programs that work look alike, with a dedicated coordinator, several professions involved, scheduled follow-up, combined interventions and patient teaching (Wu et al., 2018). Together, these findings support implementing a nurse-coordinated FLS in an outpatient orthopedic clinic, with local evaluation because certainty is moderate.
Theory: Why a Coordinator Works
The knowledge-to-action framework explains the gap as a failure to move knowledge into action rather than a lack of knowledge (Graham et al., 2006). Its action cycle, from problem identification and local adaptation through barrier assessment, tailored interventions, monitoring and evaluation to sustained change, provides both the theoretical rationale and the structure for implementation. A coordinator role directly addresses the barrier the framework would identify first: no one owns the next step.
Implementation Plan Using the Knowledge-to-Action Framework
Identify the problem: completed through the chart review and literature. Adapt knowledge to local context: build a pathway in which the clinic nurse flags each fragility fracture patient 50 or older at the first visit, using a short checklist in the electronic record. Assess barriers: interviews with surgeons, nurses and primary care partners identified unclear responsibility, limited time and patient unawareness. Select and tailor interventions: the nurse orders bone density testing under a standing protocol, provides education, communicates results and a treatment recommendation to the patient's primary care clinician, and calls the patient at three months. Monitor knowledge use: a monthly count of how many eligible patients were flagged and referred. Evaluate outcomes: the proportion starting treatment within six months, bone density tests completed, and patient understanding. Sustain: embed the checklist in the record and train backup staff.
Stakeholders were mapped before the plan was written. The orthopedic surgeons are the sponsors, since the pathway runs under their standing order; the clinic manager controls nurse time; and the primary care clinicians decide on treatment. Each received a one-page summary of the trial results with the local 7% baseline, and the surgeons agreed to a six-month pilot on the condition that the checklist adds no steps to their visit. Patients were represented by two volunteers from the clinic's advisory group, who asked that the three-month call include a plain explanation of bone density results.
Outcome Measures and Evaluation
The primary outcome is treatment initiation within six months, compared with the baseline of 7%. Process measures track identification of eligible patients and referral for bone density testing. A balancing measure will track nurse time per patient. Results will be displayed monthly on a run chart.
Conclusion
The evidence is consistent and sufficient to justify change, and the knowledge-to-action framework provides a practical path. A nurse who owns the next step after a fracture may prevent the next fracture.
References
Axelsson, K. F., Jacobsson, R., Lund, D., & Lorentzon, M. (2016). Effectiveness of a minimal resource fracture liaison service. Osteoporosis International, 27(11), 3165-3175. https://doi.org/10.1007/s00198-016-3643-2
Danazumi, M. S., Lightbody, N., & Dermody, G. (2024). Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: A systematic review and meta-analysis. Osteoporosis International, 35(7), 1133-1151. https://doi.org/10.1007/s00198-024-07052-1
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13-24. https://doi.org/10.1002/chp.47
Huntjens, K. M., van Geel, T. A., van den Bergh, J. P., van Helden, S., Willems, P., Winkens, B., Eisman, J. A., Geusens, P. P., & Brink, P. R. (2014). Fracture liaison service: Impact on subsequent nonvertebral fracture incidence and mortality. Journal of Bone and Joint Surgery, 96(4), e29. https://doi.org/10.2106/JBJS.L.00223
Li, N., Hiligsmann, M., Boonen, A., van Oostwaard, M. M., de Bot, R. T. A. L., Wyers, C. E., Bours, S. P. G., & van den Bergh, J. P. (2021). The impact of fracture liaison services on subsequent fractures and mortality: A systematic literature review and meta-analysis. Osteoporosis International, 32(8), 1517-1530. https://doi.org/10.1007/s00198-021-05911-9
Majumdar, S. R., Beaupre, L. A., Harley, C. H., Hanley, D. A., Lier, D. A., Juby, A. G., Maksymowych, W. P., Cinats, J. G., Bell, N. R., & Morrish, D. W. (2007). Use of a case manager to improve osteoporosis treatment after hip fracture: Results of a randomized controlled trial. Archives of Internal Medicine, 167(19), 2110-2115. https://doi.org/10.1001/archinte.167.19.2110
Majumdar, S. R., Johnson, J. A., Bellerose, D., McAlister, F. A., Russell, A. S., Hanley, D. A., Garg, S., Lier, D. A., Maksymowych, W. P., Morrish, D. W., & Rowe, B. H. (2011). Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: Randomized controlled pilot study. Osteoporosis International, 22(1), 223-230. https://doi.org/10.1007/s00198-010-1212-7
Majumdar, S. R., Johnson, J. A., McAlister, F. A., Bellerose, D., Russell, A. S., Hanley, D. A., Morrish, D. W., Maksymowych, W. P., & Rowe, B. H. (2008). Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: A randomized controlled trial. Canadian Medical Association Journal, 178(5), 569-575. https://doi.org/10.1503/cmaj.070981
Nakayama, A., Major, G., Holliday, E., Attia, J., & Bogduk, N. (2015). Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporosis International, 27(3), 873-879. https://doi.org/10.1007/s00198-015-3443-0
Solomon, D. H., Johnston, S. S., Boytsov, N. N., McMorrow, D., Lane, J. M., & Krohn, K. D. (2014). Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. Journal of Bone and Mineral Research, 29(9), 1929-1937. https://doi.org/10.1002/jbmr.2202
Wu, C.-H., Chen, C.-H., Chen, P.-H., Yang, J.-J., Chang, P.-C., Huang, T.-C., Bagga, S., Sharma, Y., Lin, R.-M., & Chan, D.-C. (2018). Identifying characteristics of an effective fracture liaison service: Systematic literature review. Osteoporosis International, 29(5), 1023-1047. https://doi.org/10.1007/s00198-017-4370-z
DNP 704 Module 4 instructions, in plain terms
The posted syllabus describes Paper 4 as the final summative work demonstrating mastery of all course objectives. It includes the revised content of the prior three papers plus critical appraisal of evidence, synthesis, application of a selected theory and application of an implementation framework, an EBP, QI or innovation model, to a proposed practice change. As the last of the papers that make up 80% of the grade, this one carries the most weight. Expect to condense earlier content and give most of the space to appraisal, synthesis and implementation. Check Canvas for the required framework list. Plan your writing time so the appraisal and implementation sections get the most attention, since they are the new work in this paper.
How the DNP 704 Module 4 example is put together
The paper briefly restates the background, question and search, then devotes most of its length to appraisal, synthesis and implementation. Appraisal judges each key source's design, strengths and limits and notes certainty. Synthesis states three conclusions supported across sources. A theory section explains why the proposed change should work, and the implementation section walks through each phase of the knowledge-to-action cycle with concrete steps. Outcome, process and balancing measures close the plan. The conclusion returns to the opening idea of ownership, which ties the paper together. Five sources support the plan. Each phase of the framework is tied to an action with an owner.
Reading the DNP 704 Module 4 grading rubric
Final EBP papers are usually graded on integration of revised earlier content, rigorous appraisal, a synthesis that supports a clear practice recommendation, appropriate use of a theory and an implementation framework, a feasible plan with measures, and scholarly APA writing. Faculty look for implementation plans in which each framework phase leads to a specific action. Honest discussion of evidence certainty, followed by a plan for local evaluation, shows mature reasoning. A clear link to the DNP project demonstrates purpose beyond the course. A clear primary outcome with a baseline and comparison shows readiness to evaluate a practice change. Balancing measures show awareness of unintended effects. Feasibility in the actual setting is weighed carefully.
DNP 704 Module 4 help with common mistakes
The most common weakness is a final paper that repeats the first three papers and adds a thin implementation section. Condense earlier content. Another is naming a framework without applying each step. Appraise sources critically, including limitations. Make measures specific and tied to the PICOT outcome. Keep the plan feasible for your setting. If you would like help pulling your papers into a final EBP paper, send your drafts to the desk. Give most of your words to appraisal, synthesis and implementation, since those are the new elements faculty grade most closely. Name your framework's phases explicitly. Tie each measure to the PICOT outcome. Keep the plan realistic for one clinic.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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DNP 704 Module 4 questions, answered
Where can I find a free DNP 704 Module 4 sample paper?
Paper 4 is above in full: appraisal and synthesis of fracture liaison evidence, the knowledge-to-action framework applied to a nurse-coordinated bone health pathway, and outcome measures.
What goes in the DNP 704 final paper?
Revised content of Papers 1 to 3 plus critical appraisal, synthesis, a selected theory and an implementation framework applied to a proposed practice change.
What implementation frameworks can I use in DNP 704?
The syllabus allows an EBP, QI or innovation model; the knowledge-to-action framework is one widely used option.
How do I appraise a systematic review?
Judge the search, inclusion criteria, quality assessment, heterogeneity and certainty of evidence, and note how included study designs limit conclusions.
How does the DNP 704 paper connect to the DNP project?
The syllabus describes the papers as the foundation of the DNP project, so the final plan often becomes the project proposal.