Use this template for Quality Improvement Project (QIP) Part 1:
Your name:

1. Readiness for Change Score and significance: _______

1– 15 Not ready for change now Red _____
16– 30 Possibly ready for change Yellow _____
31 – 45 Ready for change Green  _____

See Module 1 for Readiness for Change Survey

2. Quality Improvement Project Topic

  Topic: __________________________________

Choose a topic based on a need identified from the Wheel of Life assessment (See Module 1)

3. Write a Short and Long-term goal

a. Short term SMART Goal (action oriented- active tense, positive language) written as clear and concise sentence addressing one behavior change. Must be written to complete in four-week time frame:

Goal should be S.M.A.R.T. – Specific, Measurable, Attainable, Realistic & Timeframe


Example: I will eat at least one green vegetable at one meal every day for four weeks in order to improve my GI health.

b. Long term SMART Goal written as one clear and concise sentence:

Example: I will include 2 green leafy vegetables at 2 out of 3 meal times everyday to improve my mental clarity and overall health over the course of 1 year.

See this reference:

4. Evidenced Based Practice Resource

a. Is this an expert opinion from a website or is this a journal article?
b. Title of the article
c. How does this article apply to your SMART goal?
d. Summarize article content with a minimum of 5 sentences.
e. What was the purpose of the article?
f. What was the major takeaway from this resource?
g. When was it written (or date on website)? Must be within the past 10 years.
h. Cite Reference in APA format. Include article as attachment.
This site includes instructions on how to cite a reference in APA format:

Reflection journal
Reflect on your personal values and the importance of therapeutic communication and spiritual care for individuals and families across diverse settings. Address the moral, ethical, and legal aspects of nursing care in your response.
Consider this Nightingale quote to help you reflect: “Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation as any painter’s or sculptor’s work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body, the temple of God’s spirit? It is one of the Fine Arts: I had almost said, the finest of Fine Arts.”
— Florence Nightingale, first published as a eulogy to an unnamed nurse in Good Words

Please submit at least a paragraph (5 sentences) with correct spelling/grammar.

See Rubric for grading. NOTE; a zero (0) will be assigned for any of the four criteria where none of the criteria were met.

Free form comments Reflection Journal Rubric RNBS 4309
Free form comments Reflection Journal Rubric RNBS 4309
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeContent, Feelings, and Thoughts
All or almost all of the entry has a connection to the question prompt. Personal reflection of feelings and thoughts are revealed in the entry.
90 pts
This criterion is linked to a Learning OutcomeMechanics
All or almost all of the entries have correct spelling and grammar. 5 sentences minimum included. Timely submission.
10 pts
Total Points: 100

Writing SMART Goals Format
Assessing Your Readiness for Healthy Change

Use this example as a guide to help you break down your long-term outcome goals into specific, measurable, attainable, relevant, and
time-bound (SMART) behavior goals.

Most people start with an outcome goal. An example of an outcome goal is: “The overall goal I want to reach is to live healthier
and lose two inches around my waist.”
To reach an outcome, you must have behavior goals. For example: “I will walk five days a week for 30-60 minutes a day.”
The chart below shows a brainstorming process to break the behavior goal down to a weekly SMART goal.
This is an example of what the final weekly SMART goal might be: “This week I will walk 15 minutes a day at a brisk pace
for three days.”

Goal Component Example

What, when, where, and how will the behavior
be done?

I will walk regularly (at least five days a week) in the
morning to help me reduce inches around my waist.

How much, how many, and/or how often will you do
the behavior?

I will walk 30-60 minutes a day at a brisk pace five
days a week.

What are your steps to meet or reach your goal?
Set your goal low enough to be reached but high
enough to be a challenge?

week and work up to 30 minutes a day for five days a
I will start walking 15 minutes a day for three days a

week. Seven days might be too high (no room for

not enough to help me lose inches.
unexpected events or illness). One day is too low and

Is it the right behavior goal to help you meet your
overall outcome? Is it a good time in your life to be
setting this goal?

Now that my children are back in school and the
holidays are over I can start walking in the morning.

Make sure your goal includes a specific time frame
in which you will achieve it.

I will increase my time each week by five minutes
until I reach 30 minutes a day. I will add an extra
day every two to four weeks until I reach 30-60
minutes for five days a week.

Now it is your turn. Write and track your weekly SMART goal.
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