Directions: submit sections 1 – 4 and (reference-13 )

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 Introduction: The function of the introduction is to attract or grab the reader’s interest and attention.  

Directions: Submit Sections 1 – 4 and (REFERENCE-13 )

1.
Introduction: The function of the introduction is to attract or grab the reader’s interest and attention. The introduction consists of a broad overview of the project problem. The introduction should contain information that informs the reader about the basic nature and scope of the problem. References and statistics can be briefly utilized to reinforce the significance of (the importance) and the need (justification) for the project. The student is advised to begin a reference page on a separate page (the last page of the paper) entitled as the Reference page with all articles used to write this section cited in APA format. The introduction section should be presented in one to two paragraphs and should range in length between ½ of one page to 1 ½ pages maximum. In accordance with APA guidelines, there is no header for the introduction section because the introduction is clearly identified by its position in the manuscript.

2.
Statement of Purpose: This section follows the introduction. The Statement of Purpose describes the purpose of the project in one succinct and concise statement and clearly identifies to the reader what (product) is to be produced as a result of the project, who the project is intended for (participants), where the project will be utilized (the intended setting), and why the project is being developed. For example:
Statement of Purpose
The purpose of this project is to develop an educational training program (what- product) for adult mental health nurses (who) working in a psychiatric inpatient hospital setting (where) to promote understanding regarding the importance and benefits of implementing the Recovery Model into mental health nursing practice (why).

* The title of the project reflects the Statement of Purpose. For example: A Recovery Model Educational Training Program for Adult Mental Health Nurses Working in a Psychiatric Inpatient Hospital Setting.

3.
Theoretical Framework and Nursing’s Metaparadigm: This section follows the Statement of Purpose. The student chooses a nursing theory to guide and support the development of the project. A second theory from a discipline outside of nursing such as sociology, education, or management non-nursing theorist may also be used. The theoretical framework section introduces the theory and includes a discussion of the major components, concepts, definitions, assumptions, and propositions found within the theory. The theory needs to “fit” well with original concepts describing the project purpose. The student summarizes how the theory “fits” the project purpose by discussing how the theory’s main components, concepts, definitions, assumptions, and propositions are connected or related to the project purpose. The most current theory source (text) is to be used when possible as the primary reference source by the student, no secondary sources are permitted unless approved by the Project Chair. Additionally, in the theoretical framework section, the student discusses nursing’s four metaparadigm concepts (nurse, health, person, and environment) as they are defined by the nursing theorist and how each of the four metaparadigm concepts are operationally defined by the student. The theoretical definitions are cited in APA format (source, year, page). The theoretical framework section should be a minimum of 3 pages in length. This section should be presented as follows:

Theoretical Framework
Hildegard Peplau’s (2004) Interpersonal Relations in Nursing Theory is utilized as the theoretical framework for the development of this project. A brief overview of the theory is presented as well as a discussion regarding how the theory was utilized to guide the development of the project. In addition, Peplau’s (2004) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definition for nursing’s four metaparadigm concepts will be presented.

Interpersonal Relations in Nursing Theory
Hildegard Peplau is often regarded as the mother of psychiatric nursing….

Interpersonal Relations in Nursing Theory and Nursing’s Metaparadigm
In her Interpersonal Relations in Nursing Theory, Peplau (2004) defines nursing’s four metaparadigm concepts (nurse, health, patient, and environment) as follows. Nurse is defined by Peplau (2004) as…. (p.). For the purpose of this project, nurse is operationally defined as…. Peplau (2004) defines health as…. (p.). Health is operationally defined for the purpose of this project as…. Person is defined as…. (Peplau, 2004, p.). Person is operationally defined for the purpose of this project as…. Finally, environment is defined as …. (Peplau, 2004, p.). Environment is operationally defined for the purpose of the project as….

Example regarding how to summarize nursing’s four metaparadigm concepts for a theory with implied definitions for nursing’s four metaparadigm concepts:
Although Benner (2001) did not outwardly and explicitly define nursing’s four metaparadigm concepts (nursing, person, health, and environment) in her Novice to Expert theory, she described them as follows. Nursing is described by Benner (2001) as a helping role and as giving and receiving help…Nursing, for the purpose of this project, is operationally defined as a profession nurse in one of Benner’s five stages of skill acquisition…

4.
Initial Review of the Literature: This section follows the Theoretical Framework section. The initial review of the literature presents a brief summary of at least 20 articles (10 of the 20 articles should originate from North American nursing journals and populations under study must be in US or Canada) that the student has reviewed thus far describing current evidenced based research findings in the project area of interest. Articles should be published within the last 5 years to ensure and to reflect current research based evidence and practice. Additional articles may be requested by the project chair at their discretion. The initial review of the literature is a short summary of what is already known about the project area of interest, what has been successfully implemented, what is lacking and in need of further exploration, and articles emphasizing use of the theoretical framework chosen by the student as it pertains to the project area of interest. At times, classic and seminal work older than the 5-year limit can be included in the review of the literature since they are timeless and continue to support current practice. The Initial Review of the Literature is written following APA format and should include subheadings addressing areas of the literature explored. The Initial Review of the
Literature section should be presented as follows:

Initial Review of the Literature
A review of nursing and health related literature will be conducted to explore (project area of interest) using the following keywords both singularly and in multiple combinations: ___, ___, ____….. Databases searched, limited to the years ___ and ___, will include AMED, Alt Health Watch, CINAHL Plus with Full Text, and EBSCO. The search is limited to the years ____ to ____ to ensure that current evidence-based literature is reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.

Prevalence of Mental Illness
According to Smith (2011), approximately 1 million people have been diagnosed with a mental illness….

Defining Recovery
Currently, numerous definitions of recovery exist in nursing and health related literature…

* After a student successfully defends Chapter I (the Project Proposal), the initial review of the literature is then moved into Chapter II with a section replacing the initial review of the literature in Chapter I entitled Literature Synopsis. The Literature Synopsis section in Chapter I presents a summary of literature review findings in Chapter II once the literature review is completed in Chapter II.

Initial Review of the Literature
This section follows the Theoretical Framework section. The initial review of the literature presents a brief summary of at least 20 articles (10 from nursing sources) from North American journals that the student has reviewed thus far describing current evidence-based research findings in the project area of interest. Based on the project topic and current relevant research conducted outside of North America, the student may utilize International Journals with the permission of their project chair. Articles should be published within the last 5 years to ensure and to reflect current research based evidence and practice. Additional articles may be requested by the project chair at their discretion. The initial review of the literature is a short summary of what is already known about the project area of interest, what has been successfully implemented, what is lacking and in need of further exploration, and articles emphasizing use of the theoretical framework chosen by the student as it pertains to the project area of interest. At times, classic and seminal work older than the 5-year limit can be included in the review of the literature since they are timeless and continue to support current practice. The Initial Review of the Literature is written following APA format and should include subheadings addressing areas of the literature explored. The Initial Review of the Literature section should be presented as follows:

Initial Review of the Literature
A review of nursing and health related literature will be conducted to explore (project area of interest) using the following keywords both singularly and in multiple combinations: ___, ___, ____…. Databases searched, limited to the years ___ and ___, will include AMED, Alt Health Watch, CINAHL Plus with Full Text, and EBSCO. The search is limited to the years ____ to ____ to ensure that current evidence-based literature is reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.

* After a student successfully defends Chapter I (the Project Proposal), the initial review of the literature is then moved into Chapter II with a section replacing the initial review of the literature in Chapter I entitled Literature Synopsis. The Literature Synopsis section in Chapter I presents a summary of literature review findings in Chapter II once the literature review is completed in Chapter II.

13. 
APA References: All project proposals are required to be written following APA formatting and style using the APA Manual 6th edition. Students are expected to begin a separate page for their reference list from the time they begin writing Chapter 1 of the proposal. The reference page is entitled References

1

1

1

A RESOURCE GUIDE FOR NURSES IN THE HOSPITAL SETTING TO IDENTIFY

PATIENT NEEDS AT DISCHARGE

By

Student name

A Project

Submitted to the Faculty of D’Youville

Division of Academic Affairs in partial fulfillment of the requirements for the degree of

Master of Science

in

Nursing management and quality leadership

Buffalo, NY

[Month day, year]

Copyright © 2022 by student name. All rights reserved. No part of this project may be copied or reproduced in any form or by any means without the written permission of NAME .

PROJECT APPROVAL

Project Committee Chairperson

Name: ______
__student name __________________________________________

Signature: __________________________________________________________

Discipline:____
___Nursing____________________________________________

Project Defended

On

[Month Day, Year]

Abstract

The project problem states, “How can nurses provide additional support for elderly patients when their main concerns revolve around the home as a place of fear for their return?” Due to the nature of the nursing workload in the hospital setting, discharge planning tends to be pushed aside due to other priorities. However, it is important that as much as patients are cared for in the inpatient setting, they also need proper preparations for their home setting. The project’s purpose is to provide assistance for nurses and develop a nursing resource guide with regards to important points needed in discharge planning. Dorothea Orem’s Self-Care Deficit nursing theory (Orem, 1991; Orem et al., 2003) is utilized as the theoretical framework for the project. Five content experts will review the resource guide for content validity.

Table of Contents
Chapter
I. PROJECT INTRODUCTION……………………………………..…….8
Statement of Purpose 9
Theoretical Framework 9
Initial Review of the Literature 18
Significance and Justification 31
Project Objectives 31
Definition of Terms 32
Project Limitations 32
Project Development Plan 32
Plan for Protection of Human Subjects 33
Plan for Project Evaluation 34
Summary 35

II. REVIEW OF LITERATURE ………………………………………… Summary ………………………………………………………………

III. PROJECT DEVELOPMENT PLAN…………………………………. Project Setting and Population………………………………………..

Content Expert Participants …………………………………….……. Data Collection Methods …………………………………….….…….

Project Tools ……………….……….…….…………………………. The Protection of Human Subjects ………………………….………

Summary ……………………………………………………………..

IV. PROJECT EVALUATION, IMPLICATIONS, AND FUTURE RECOMMENDATIONS

……………………………………………………………………..………..

Project Evaluation …………………………..…………….….……..

Implications for Future Practice ………….………………….……..

Future Recommendations …………………………………………..

Summary …………………………………………………………….

References …………………………………………………………..36

Appendices ………………………………………………………….41

List of Appendices

Appendix

A D’Youville Patricia H. Garman School of Nursing Full Approval Letter

…………………….………………………………………………………………..41

B Letter of Intent ………………………………………………………42

C Evaluation Tool ……………………………………..………………44

D Resource Guide…………………………..………………………………..

E Survey tool results in graph………………………………………….47

Chapter I

Hospital readmission of recently discharged patients is a common, yet undesirable, occurrence. The goal is that when patients are discharged from the hospital, they stay home because having a reduced number of readmitted patients in hospital settings reflects the higher quality of patient care provided by the health care system (Dols et al., 2018). However, it is also quite common to see patients, especially those with advanced age, admitted to hospital with the diagnosis of “failure to cope”, as seen by this project author at the bedside. The literature also provides information on patients being readmitted to the hospital weeks or months postdischarge. One such study by Yen et al. (2022) provides results indicating that 14.3% of their 300 patient sample (all above 80 years of age) were readmitted to the hospital 30 days after discharge. This percentage also increased to 19.7% and 43% at 60 days and one year post hospital discharge, respectively. Verna et al. (2022) and Ayatollahi et al. (2018) relate hospital readmissions to patient comorbidities and diagnoses involving cardiovascular disease, diabetes, respiratory illness, and kidney disease. Verna et al.’s (2022) findings also relate hospital readmission to a shorter hospital stay, which causes a return to the hospital within 10 days of their recent discharge. When patients are discharged and readmitted back to the hospital, it makes one wonder why they are happening and what else can be done to prevent readmissions. Nurses are the health care profession that spends the most time with patients at the bedside from admission to discharge, hence nurses can have the most impact on patient needs.

This raises the question: how can nurses provide further support for elderly patients when their main concerns revolve around the home as a place of fear for their return? Dorothea E. Orem’s self-care deficit nursing theory (SCDNT) is the theoretical framework that fits this area of concern. Through the guidance of an initial review of the literature, this project aims to provide clarity and background on the needs surrounding discharge planning; what nurses can do; and how nurses can be supported in doing so.

Statement of Purpose

The purpose of this project is to develop a resource guide for nurses in the hospital

setting to identify the patient’s needs at discharge.


Theoretical Framework

Dorothea E. Orem’s (1991) self-care deficit nursing theory is utilized as the theoretical framework for the development of this project. A brief overview of the theory is presented as well as a discussion regarding how the theory was utilized to guide the development of the project. In addition, Orem’s (1991) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definitions for nursing’s four metaparadigm concepts will be presented.

Self-Care Deficit Nursing Theory

Dorothea E. Orem’s impact on nursing reflects on her work towards developing and establishing her self-care deficit nursing theory (SCDNT). Her theory development began with the reflection question: “What condition exists in a person when that person or a family member or the attending physician or a nurse makes the judgment that the person should be under nursing care?” (Orem, 1991, p. 61). In the fourth edition of her book,
Nursing: Concepts of Practice, Orem explained that the journey towards her theory development began with the need to define nursing, identify when a nurse is needed, and the support a nurse can provide a patient.

The self-care deficit nursing theory is divided into three theories: the
theory of selfcare; the
theory of self-care deficit; and the
theory of nursing system (Orem, 1991). In order to understand the theory, it is important to first have an understanding of its major concepts:
selfcare, self-care agency, self-care demands, nursing agency, self-care deficit, and
conditioning factors (Orem et al., 2003)
.
Self-care is defined as the person’s general act of providing necessary everyday needs for themselves in order to maintain human function and well-being.
Self-care agency is the person’s learned competence to practice self-care.
Self-care demands refer to the actual actions that are necessary for the person’s body to maintain health, e.g., feeding oneself independently. Without these actions, the person’s health will deteriorate.
Nursing agency refers to the nurse’s ability to assess and provide a care plan that matches the needs of the patient.
Selfcare deficit is the lack of the person’s
self-care agency to provide for the
self-care demands. Conditioning factors refer to elements that can affect a person’s ability to practice self-care, such as age, gender, developmental state, sociocultural influences, lifestyle habits, and health status.

The Theory of Self-Care

The
theory of self-care centralizes on the idea of a person who is able to provide requirements that are essential for the maintenance of life and function. Orem called these requirements “universal self-care requisites” and they refer to a person’s basic needs, including sufficient intake of air, water, and nutrients
, elimination of body waste
, providing the body the balance between activity and rest
, privacy and social interaction/human relationships
, and prevention of illness (which also includes seeking medical assistance when ill) (Orem, 1991, p. 126). As an alternative to self-care, Orem (1991) identifies that there are individuals who are not able to provide their own self-care as part of their baseline function, e.g., children or seniors. Therefore, Orem referred to this as dependent care, where someone who is capable will be the person to provide self-care actions to the individual who is dependent.

Orem (1991) provided assumptions and propositions within the theory of self-care.

According to Orem (1991), the theory of self-care assumes that all individuals have the possibility to learn how to develop and provide self-care as well as dependent care. This results in the assumption that one can learn to see recurring patterns of needs, allowing one to form a self-care and dependent care routine towards the repeating self-care or dependent care demands. The theory also assumes that self-care requisites are met with the influence of one’s culture and social influences. Therefore, it assumes that the action of self-care and dependent care depends on the person’s preference in how they respond given a certain event.

The theory of self-care, as per Orem (1991), provides the proposition that regularly practiced acts of self-care will be applied effectively and successfully. It also proposes that the act of self-care is in response to the best of the person’s knowledge of how the self-care needs can be met. Self-care also involves the use of materials needed to complete the act of self-care. It also proposes that externally projected self-care is observable (e.g., the ability to mobilize independently), while those that are internally projected can only be observed through collecting information from the person (e.g., the person’s motivation to practice mobility to gain progress). Another proposal under this theory explains that self-care that is routinely done over time forms a
self-care system where the person will be able to identify and predict how their actions will result in their self-care. It also allows the person to learn to adjust and adapt to change, e.g., learning and taking new medications as prescribed.


The Theory of Self-Care Deficit

The
theory of self-care deficit explains how nursing is needed by the person who is unable to provide self-care (Orem et al., 2003). Orem (1991) explains that the person’s inability to provide self-care could be due to issues related to their health or brought forth by interventions for their health care. Examples of this include weakness from treatment such as chemotherapy that disables a person’s level of energy and requires them to take medications that counteract the side effects of treatment. Another example is that of surgery. Depending on the type of surgery, multiple organ systems can be affected as well as the person’s mobility. Nursing is essential for these patients in order to accommodate the inability of the person to provide specific self-care practices.

Assumptions that are identified by Orem (1991) within the theory of self-care deficit are divided into people who have the capability to provide self-care and those who are relying on dependent care. For those who can have the ability to provide self-care, this theory assumes that a person should be able to manage their self-care in a stable environment but also be able to identify their limits in certain situations. It also assumes that a person’s participation in self-care depends on their values and outlook toward their health and life, cultural beliefs, and influences from their social circle. For those who are dependent on their care, it is assumed that the health care system and available community resources will provide assistance for the person, such as nursing care, if needed. It also assumes that if a person is a part of a facility, for instance, a longterm care home, this becomes the patient’s main means of acquiring the care that they need. The propositions provided by Orem’s (1991) theory of self-care deficit include the idea that those who are able to participate in self-care or dependent care are under the influence of the conditioning factors mentioned above. The theory also proposes that nursing is necessary when the self-care ability of the person is not able to meet the self-care demands. It also adds that nursing is necessary when there is anticipation that the patient will not be able to practice selfcare immediately e.g., post-surgical care.

The Theory of Nursing System

The theory of nursing system establishes nursing agency and the structure of nursing the patient needs and is divided into three types
: wholly compensatory, partially compensatory and
supportive educative system (Orem et al., 2003).
Wholly compensatory defines the inability for self-care agency to meet self-care demands. The patient is unable to practice self-care that meets their body’s needs therefore this is when nursing is needed as a temporary substitute to assist the patient with their self-care needs until they are able to attend to them themselves.
Partially compensatory is identified when the patient is able to practice some self-care activities, is not fully dependent on the nurse and the nurse’s role changes to an assistive role.
Supportive educative system requires the more minimal amount of nursing assistance as the nurse takes on a more supportive role where they are there to supervise or guide the patient to further strengthen their self-care agency.

The assumptions provided by Orem (1991) toward the theory of nursing system describes the role of the nurse as part of patient care that is time-limited as long as the patient needs assistance in self-care activities until they are able to practice them independently. The theory also includes in its assumption that nursing is a profession that acts within its scope of practice under a governing body that provides a focus to the profession.

Propositions suggested by Orem (1991) to reflect the theory of nursing system include the relationship between the nurse and the patient, who has specific self-care requisites but cannot meet the demands. Nurses in turn, attend to the patient by identifying the patient’s selfcare requisites that need assisting and formulating a care plan to support the patient into practicing independent self-care. Through assessment, the nurse is able to know the patient’s capabilities regarding the patient’s self-care agency therefore will increase or decrease the amount of support given to the patient. Lastly, the theory proposes that the nurse and patient work collaboratively in order for the patient to improve towards meeting their own self-care demand through practice of self-care as independently as possible.

Graduate Student Project and Orem’s Theory

With the advancement of science and medical interventions, comes prolonged life for the general population. With that said, humans are living longer, resulting in patient populations reaching ages in their 100s, as seen by this writer at the bedside. From this writer’s nursing experience, while the healthcare system provides great care for illness and treats the cause of disease, it has not solved the emerging issues regarding the coping mechanisms of elderly patients as they continue to live their lives at home. The goal of medicine is to treat illness, yet patients come into the hospital system with the admitting diagnosis of “failure to cope.” This brings back the question for the project: How can nurses provide further support for elderly patients when their main concerns revolve around the home as a place of fear for their return? This issue fits well with Orem’s self-care deficit nursing theory because the patient’s inability to cope at home translates to their inability to practice self-care. The elderly person becomes someone who identifies with
dependent care and becomes admitted to the hospital due to “failure to cope.”

Self-Care Deficit Nursing Theory and Nursing’s Metaparadigm

Orem did not directly relate her theory to the metaparadigm concepts of
person, environment, health, and nursing, but she clearly communicated in her writings how each contributed to her theory’s meaning. According to Orem’s (1991) self-care deficit nursing theory, understanding the
person is to understand that they initially
refer to an individual who is able to provide basic human needs for themselves (self-care agents) through learned experiences, enabling them to practice self-care. The
person can also refer to someone who is of dependent status where they are unable to practice self-care as they are incapable of doing so and therefore rely on family or their caregiver to provide their self-care actions for them. The
person is also identified as someone who is unable to practice self-care due to medical or health care intervention reasons (Orem, 1991). The
person becomes a patient who needs assistance, training, and guidance to be able to practice self-care again with the help of nursing. For the purpose of the project, the
person is operationally defined as the patient who is receiving care due to their inability to cope and function at home. The
person could be in a position where they are unable to practice
self-care with or without support and hence is admitted to a hospital to seek assistance. The main issue for these patients could simply be a lack of energy or being too weak to mobilize and participate in self-care activities. The patients may or may not have underlying medical issues that are causing a lack of participation in their activities of daily living.

Although the
person refers to the individual, Orem (1991) makes it a point to emphasize that the
person is not isolated by the self. Orem (1991) explains that humans should be seen as functioning “biologically, symbolically, and socially” as someone who comes from a place with their own responsibility and role towards others (p. 181). This introduces nursing’s metaparadigm concept of the
environment. Orem (1991) explains that a
person is consistently linked to their
environment. Individuals exist within their environment, which Orem explains as features that are physiochemical, biologic, socioeconomic-cultural
, and
community in nature (Orem, 1991). Physiochemical
features of the environment refer to the air, pollutants, weather, and the status of the earth’s stability. Biologic features
involve animals, including the person’s pets, infectious organisms, and other people or animals that can be agents of bacteria or diseases. Socioeconomic-cultural features refer to the
person’s family, their role and relationship with their family, cultural values, dynamics, as well as beliefs that could affect their decision making. Community
refers
to a person’s access to health care services, resources for cultural and healthcare needs, as well as accessibility. Overall, it is important to have an understanding that their type of environment affects how patients perceive their care and the decisions they make regarding their care plan. E
nvironment is operationally defined, for the purposes of the project, as a location that begins at the hospital and ends at their home. Cultural beliefs, social support, financial status, educational level, and accessibility of health care resources and availability from the area they live in are also vital information that is important to understand as the person is transitioned to their
environment. Home can be defined as their place of residence, whether it is in an apartment, house, long term care home or retirement home where they may or may not live alone.

Orem (1991) sees
health as an element that can affect a
person’s ability to practice selfcare. This is because Orem (1991) views
health as synonymous with
wholeness” and a change in this structure would be an “absence” toward one’s
health (p. 179). Orem (1991) also explains that
health is not the responsibility of one individual.
Health is a societal responsibility, because the mental, interpersonal, and physical aspects of
health are all linked to the
person. When one becomes ill, it is not always possible to focus only on healing and treatment. The person’s
environment becomes a factor that plays into the patient’s ability to attend to their
health. If they are the sole breadwinner of their family or they are the primary caregiver of their sick relative, it becomes difficult for them to focus on their health due to the circumstances of their responsibilities. Therefore, this places a demand on the societal responsibilities toward a person’s health and involves necessary assistance that can be provided in order for the individual to focus and become an independent self-care agent once more.
Health is operationally defined as the person’s subjective view of themselves when faced with illness or a deficit in their ability to function. It is important to understand how the
person defines
health and what is most important to them, as well as their goals.
Health should be discussed with the person’s caregiver as well (if possible) in order to properly communicate goals for home and the reality of the elderly patient’s own capability to provide self-care. This writer agrees with Orem’s definition of
health as a societal responsibility where assistance towards one’s wellness journey also depends on the responsibilities and services that are available to provide assistance for them. It will be difficult for a patient to return home if there are no available resources to help them be managed at home. Hence, it is the nurse’s role to have an understanding of not only the patient’s current state but also their social history.

Orem (1991) sees the metaparadigm of
nursing as synonymous with her concept of
nursing agency, where nursing is necessary as a complement to a patient’s inability to practice self-care. The presence of nursing allows the person to appropriately rely on the nurse as someone who can provide a care plan that adjusts to the patient’s improvement or decline and provide assistance throughout their health care journey.
Nursing should have an understanding of the
person as someone who comes with certain cultural values and beliefs that can affect their outlook on health and wellness. Orem (1991) explains that nurses and their patients should work together and form a good working relationship where they have an understanding of the goals that meet the needs of the patient while keeping in mind what is most important to them in their
environment.
Nursing is operationally defined in the project as those in the nursing profession that approach patient care with a holistic perspective. The patient is not to be seen as an individual who is simply admitted for limitations in their physical function. The role of
nursing proves effective when they have a better understanding of the patient and how the patient perceives their care. If the patient is unable to make their own decisions due to impairment in their cognition, it is part of the nurse’s role to communicate with the patient’s caregiver (someone who is providing
dependent
care) to understand the patient’s capabilities, wishes, and concerns.

It is also important for the nurse to present information to the health care team regarding the patient’s situation at home and consult with the proper allied health professions to further assist in the patient’s potential need for health care support once they return home.


Initial Review of the Literature

A review of nursing and health related literature was conducted to explore discharge planning using the following keywords both singularly and in multiple combinations:

discharge planning, nursing, research, study, elderly, discharge preparedness, community nursing, and
self-care. Databases searched, limited to the years 2017 and 2022, will include, CINAHL Plus with Full Text, EBSCO, Google Scholar and the D’Youville library to loan articles through interlibrary loan. The search is limited to the years 2017 to 2022 to ensure that current evidence-based literature is reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.

Patient Attitudes Toward Self-Care and Discharge Planning

There are dynamics that define how a patient views their hospital discharge planning. Some might find the process easy and simple as they are now ready to return to their usual routine and practice self-care, but other patients might find the process challenging. One would assume that achieving safety at home could be a challenge or a cause of fear for both the patients and their caregivers. A study by Schreiner and Daly (2020) provides clarity on this assumption in that they found that age is not an indicator of a patient feeling “treatment burden” or pressure regarding the amount of care they would need on a daily basis due to medical conditions (p. 158). Schreiner and Daly’s (2020) findings indicate that if patients receive support from family or caregivers regarding their care, their perception of their care needs does not reach a high level of treatment burden but only a moderate amount. On the other hand, this does not mean that there is less treatment burden as long as one has support. Evidence from the study indicates that patients’ levels of treatment burden increase during their discharge planning process as they transition from hospital to home. Having multiple chronic illnesses is also an element that increases a patient’s treatment burden, but ultimately, those who receive support in their daily care have shown a decrease in and a lower level of perceived treatment burden. However, this does not specify the quality of support provided by the caregiver. Relying on caregivers can also have a negative impact on a patient’s adherence to their care needs. Qualitative data from Beckner et al. (2021) reveals that patients who rely on caregivers are also at the caregiver’s mercy. Some patients in the study are unable to properly take their medications because the caregiver had possession of the medications, did not fill the prescription due to unavailability, or simply a lack of education about the medications’ importance. At the same time, when patients are less reliant on others for care, their personalities and attitudes toward their own care play a role in home selfmanagement. Results in Beckner et al.’s (2021) research also provide information about this. Some patients in the study refused to be taught by nursing staff because they preferred to hear from doctors, or they disagreed with the provider’s decision to discontinue certain medications, so they continued to take them. Medication cost also presents a barrier towards following medication administration instructions, as does a lack of education on the medications, transportation to fill the prescription, and, in some cases, pharmacy errors.

A patient’s place within certain social demographics also plays a part in how they may perceive their hospital discharge and health management afterwards. Study findings in research by Al-Maskari et al. (2021) show that of the post-op patients who were part of the sample, those who have higher levels of education and are currently working tend to show priority on learning about their hospitalization and discharge. Males and those who are married tend to veer towards learning more about the details of physical activity, while females tend to veer towards learning about medications and other details. Additionally, those who have a higher income tend to prioritize learning about function, mobility, and physical activities compared to those who make less. Culture also plays a role in prioritizing certain health management practices. In a study by Tawalbeh et al. (2020), they found in their results that a patient’s ability to recognize the importance of certain health practices depends on ethnic and cultural practices. Specifically, in Tawalbeh et al.’s (2020) study, patients who were taught heart failure self-care strategies were easily able to practice a low-salt diet, do some physical activities, and attend their doctor’s appointments. However, the least followed self-care behaviors included practicing illness avoidance, checking for edema, such as ankle swelling, and doing at least 30 minutes of exercise per day. The researchers found that the sample in the study did not understand the importance of exercise due to the nature of the culture of the population. However, in addition to the information from the study by Al-Maskari et al. (2021), Tawalbeh et al.’s (2020) research also includes evidence that those with high income and education tend to show more interest in learning about health maintenance. Moreover, being of a younger age, living with more people at home, and not following other traditional treatment regimens also relate to a higher interest in learning.

In the hospital setting, there is the factor of the patient’s perception of discharge readiness. Baksi et al.’s (2021) study on the examination of this topic reveals that patients who present with more preparedness and readiness for discharge are those with higher levels of education, which aligns with the results in Al-Maskari et al.’s (2021) and Tawalbeh et al.’s (2020) studies. Furthermore, satisfaction with the nursing care they receive, having support at home, and being male all contribute to discharge readiness (Baksi et al., 2021). Those who live alone, are single, have a lower level of education, and have longer hospital stays, on the other hand, have lower levels of confidence in their discharge.

Outside of the patient’s willingness or unwillingness to learn self-care at the point of discharge, a patient’s ability to learn and follow health management education also plays a part in the patient’s capability to provide self-care in their home. In the hospital setting, patients are not only presenting with a pattern of longer hospital admissions (i.e., an average length of stay of 26 days in 2013 compared to 28 days in 2015), but patients are also presenting with more cognitive and functional impairment or physical impairment and depression compared to previous years (Popejoy et al., 2021). Cognition is a critical issue when it comes to the discharge process, especially for patients who have dementia. The research findings by Prusaczyk et al. (2019) explain that patients with dementia tend to have functional impairments that require them to be more wheelchair dependent, showing support for the study results by Popejoy et al. (2021). Patients with dementia are also less likely to report accurate past medical histories, retain discharge-related teaching, or receive discharge education at all due to their known memory issues, resulting in hospital readmission or being discharged to another facility (Prusaczyk et al.,

2019).

Nursing and Discharge Planning

Nurses are often the last health care professionals a patient sees when leaving the hospital during discharge (Davisson & Swanson, 2020a). With this knowledge, it is safe to identify that nurses should have a main role in discharge planning for patients. However, this is not always the case. Studies done by Davisson and Swanson (2020b) and Hayajneh et al. (2020) on nurses’ positions towards discharge planning show a general disapproval of nurses’ participation in discharge planning. According to the nurses, many of the barriers to discharge planning in the results are due to a lack of time, which can be worsened by the existence of a language barrier, a high patient load, and assignment acuity, resulting in nurses stating that urgent tasks would be prioritized over discharge planning. Nurses in Davisson and Swanson’s (2020b) study also voice that they do not feel a structured process of discharge planning guided by the hospital’s policy and discharge planning only adds more responsibility to their role. General results from Hayajneh et al.’s (2020) research find that nurses have little knowledge of discharge planning in all aspects, including goals of discharge planning, who can and should be involved, the role of the patient care manager, and who is best to assess the patient’s needs toward discharge planning. The nurses in the study rely on the physicians regarding discharge planning and instructions, therefore causing the impression that discharge planning is not within the nursing scope of practice and that they do not have the autonomy to practice discharge planning.

Contrary to the results of Hayajneh et al.’s (2020) study, there is acknowledgement from other nurses regarding discharge planning. A nurse in Davisson and Swanson’s (2020b) study acknowledges that assisting in discharge planning should start at the point of admission. Another nurse states, “We know what we should be doing. We know what it means for the patient. What is it that we need to accomplish on this admission to make this patient not come back so soon? We need to work on that so that we don’t go in as individuals, going in as a team, pulling on the same string “(p. 4). This shows that there is an understanding of the importance of discharge planning but also a lack of unity as a team towards discharge planning. Further concerns brought up by the nurses in Davisson and Swanson’s (2020a) study include the lack of communication as shown by sudden, unplanned discharges, whereby by that point, teaching becomes a barrier for the patients as they tend to only focus on wanting to leave the hospital, leaving no time for the nurse to provide discharge education due to patient dismissal.

Despite the fact that the studies above show a negative attitude toward discharge planning, studies also show that this is not the consensus. Hayajneh et al. (2020) identify that nurses who have a lower number of patients, work in teaching hospitals and within certain specialty areas such as the intensive care units and acute wards, tend to have more knowledge and positivity toward discharge planning. Due to the nature of a nurse’s routine, medication teaching is also seen as an important part of discharge planning by the nurses (Hayajneh et al., 2020). Davisson and Swanson (2020a) also provide their study results on the importance of relationships nurses build with their patients. Nurses voice that having good rapport with their patients helps them want to look further into the patient’s discharge barrier and reasons for frequent readmissions. Newer nurses also report that due to their lack of experience, it feels more proper to rely on the more experienced nurses’ knowledge to provide teaching to patients. AlMaskari et al. (2021) expanded on this by complementing that as nurses gain more experience through years of practice, they tend to provide teaching on specific details such as anatomy and physiology concerning the patient’s condition, when to seek medical help, and resources for the family to learn post-discharge.

It is important to understand that although there are reasons why nurses might not participate in or acknowledge the importance of discharge planning, there are also reasons why they might do so. At the same time, there are also situations, such as a lighter workload and level of nursing experience, that allow nurses to support discharge.

Discharge Assessment Tools

The literature discusses multiple tools to help guide discharge planning for the health care team. One study by Kawar et al. (2021) focuses on the addition of a mobility ambulation assessment tool into the electronic health record system as part of the nurses’ routine documentation. This tool was received well and was also accepted by the nurses. The nurses indicated that this tool made it easier during transfer of accountability reports such as shift change. The tool also allows the nurses to anticipate needs and identify those who would need further intervention as well as discharge planning because it shows the patient’s progress and decline in mobility. Similar results were found in studies using another tool called the Readiness for Hospital Discharge Scale (RHDS). Bobay et al.’s (2018) study results find the RHDS tool effective as it provides nurses the guidance needed in order to assess a patient’s readiness to go home as they reach the end of their hospital stay. The study finds the tool reliable and also predictive of those at risk of hospital readmission or return to the emergency department within 30 days of discharge. RHDS also allows studies such as that of Baksi et al.’s (2021) to gather data pertaining to readiness for discharge in relation to social demographics of patients as per a previous discussion above.

Frailty risk score (FRS) is also a risk assessment tool that is seen in the literature as effective in aiding in needs prediction. Much like the mobility assessment tool, this is also incorporated into the electronic health records as part of nursing documentation. Results from a study by Lekan et al. (2021) directly relate a patient’s FRS to the risk of hospital readmission within 30 days of discharge. A later study by Lekan et al. (2022) adds the ability of FRS to also predict patient mortality in the hospital setting. Both studies provide emphasis on the importance of the FRS as a guide for nurses and other health care professionals to better consider who would need further attention towards better interventions and discharge planning, while also including the patient’s caregiver in the process, if applicable.

On a more specific note relating to the ability of patients to apply self-care, Grenier et al. (2022) introduce the use of the performance assessment self-care skills (PASS) tool in order to asses a patient’s ability to perform their activities of daily living (ADL). This study focuses on the occupational therapy (OT) profession, where the OTs’ use of the tool has shown effectiveness in predicting the risk of hospital readmission and emergency department visits. Specifically to PASS, a patient’s inability to use the telephone and take their medications independently is found to be directly related to the high risk events for the patient after hospital discharge, causing a need for hospital readmission. Specific results within the tool also reveal that the ability to prepare meals and having physical disabilities (without cognitive impairment) do not indicate a risk or increase in risk for hospital readmission.

While the aforementioned assessment tools help predict the risk of hospital readmission or mortality within the hospital, there is a program found in the literature that is specific to the discharge planning process. The Reengineered Discharge (RED) program has shown promise in the literature by Popejoy et al. (2019) and later on also by Popejoy et al. (2021). The program takes into account language preference, ensuring follow-up appointments are set up, medical equipment and outpatient needs are organized, teaching and education is done with patients and families with an assessment to confirm their understanding, making sure that patients know what to do when faced with an emergency or issues at home, and telephone communication regarding discharge plans. The level of understanding of the patient’s home location, culture, and language is an important part of ensuring that when education is given to patients going home from the hospital, each education plan is done so with an individualized understanding of the patient and the environment they will go home to, if not, risking hospital return (Davisson & Swanson, 2020;

Dols et al., 2018). Both of the studies by Popejoy et al. (2019; 2021) used skilled nursing facilities (SNF) to implement the program with the goal of improving the discharge planning process for patients ready to go back home to their own community. The results of Popejoy et al.’s (2019) study show some promise. However, the program was not as well received by the nurses, contrary to the authors’ prediction. Barriers were mainly related to the implementation of change in the facilities and a lack of support from the leadership level. The succeeding study continues to pursue the implementation of the RED program into SNFs and has shown better staff acceptance through a slower implementation process (Popejoy et al., 2021). This study emphasizes the importance of management support, as change will not occur without the support of those in the leadership level, even if staff try to engage in change.

Overall, not all new implementations of tools or programs can be expected to be successful. However, it is important to understand areas of improvement from study results, how the change was received, and what elements made it work or not work. Ultimately, without support from staff and management, promotion of change will continue to be a challenge and issues with discharge planning will continue to develop as the population continues to show more cognitive and functional impairment as well as longer hospital stays (Popejoy et al., 2021).

Supporting the nurse at discharge planning

In order for nurses to provide support for their patients during discharge, nurses should also be supported in order for them to do what they do best with the best quality they can provide. Support can be in the form of leadership support, allied health involvement, education provided, and having the knowledge of resources that would benefit the patient.

As previously mentioned in the research study by Popejoy et al. (2019; 2021), it is difficult to implement new programs that support change and progress without support from management. The absence of support creates a barrier and reduces the quality of discharge planning. It is the role of those in management to ensure adequate staffing is present and, by having the ideal nursing workload compared to a heavier workload due to short-staffing, will help elevate the views of nurses toward discharge planning and will also acquire better cooperation toward its implementation (Hayajneh et al., 2020). According to research, involving the multidisciplinary team (e.g., social worker, physiotherapist, occupational therapist, dietician) in discharge planning is also important due to their added perspective, completing a full overall knowledge about the patients from the medical, social, and physical concerns they may have (Popejoy et al., 2021; Grenier et al., 2022). For example, Grenier et al.’s (2022) study not only supports the use of the PASS tool, as mentioned previously, but its results also emphasize that the team needs to rely on OTs and understand that their knowledge and insight are evidently useful in the prediction of hospital readmissions. Therefore, the researchers suggest that if OTs voice their concerns about a patient’s safety at home, homecare services need to be in place for the patient as they are at a high risk for events at home that would cause a hospital readmission or visit to the emergency department.

Research such as that of Popejoy et al. (2019; 2021) finds that there is evidence for nursing staff acceptance of new practice implementations when they receive education. Otherwise, there will be resistance to change. In order to support nurses with discharge planning, it is important that they are given proper guidance in order to apply this skill in practice. This guidance can be in the form of education provided to nurses, such as that of the teach-back method. In a study by Scott et al. (2019), the researchers identified that the teach-back method encourages patients to not only receive information from their health care team but also allows them to participate in their care and education. During the study period, the participating nurses were given education sessions on how to properly relay their teaching to patients, such as how to speak clearly, access education materials with minimal medical jargon, and ask patients to repeat what has been taught in their own understanding (teach-back). The teach-back method allows the nurse and patient to learn what the patient understands and needs clarification on. This study provides evidence that the teach-back method is a useful teaching skill that nurses can apply to ease the stress (i.e., treatment burden) of patients as they transition from hospital to home. Another study finding provides an example that providing education through simulation activities within a learning environment increases a nurse’s self-efficacy in practice (Genuino, 2018). Genuino’s (2018) study results indicate that a nurse’s age, experience, and further education achieved does not affect a nurse’s level of self-efficacy when it comes to providing patient education about their diagnosis and self-management at home (e.g. heart failure and chronic obstructive pulmonary disease management).

Knowing what resources to refer patients to is advantageous for successful discharge planning as it enables patients to discuss their care. For example, Whitehouse et al.’s (2020) study validates the efficacy of a diabetes self-management education and support (DSMES) program delivered in the community through telehealth. The study recognizes that the postdischarge period of a patient is not only a moment of the highest risk of rehospitalization but also the time that provides the ability to deliver the most education to patients and their caregivers. As a result, providing information about community resources to nurses at the bedside not only reduces the likelihood of hospital readmission but also empowers patients in their own care. Without a nurse’s ability to properly provide a patient the education they need to manage their health at home, there is no successful discharge planning and patients will be at a higher risk for readmission to the hospital. Readmissions, in turn, decrease a patient’s quality of life, which is proven to directly relate to a patient’s readmission rate post-hospital discharge (Leavitt et al., 2020).

As previously mentioned in Davisson and Swanson’s (2020) study, discharge planning should start at the point of admission. In their study findings, Beckner et al. (2021) indicate the importance of linking patients to appropriate home care services (e.g., nursing support at home with medications) and how it should start at the bedside. Nurses can start the education delivery to patients and provide information to the home care services in the community at discharge in order to assist with continuity of care at the patient’s own home. The literature also stresses the involvement of caregivers in the discharge planning process to help ease the patient’s transition back home. While it was previously mentioned by Beckner et al. (2021) that there are disadvantages to the dependency of patients with their caregivers, there are also studies that prove otherwise. A study by Agarwal et al. (2020) recognizes that the cognitive impairment of patients has the tendency to worsen their heart failure management, which increases symptoms and admission rates. This study looks into the involvement of caregivers in relation to this issue and reports that patients in the study who had caregiver involvement during their hospital discharge process have a lower readmission rate 30 days after hospital discharge. This result compares to the low readmission rate of patients with no cognitive impairment and who are able to manage their heart failure management at home. In comparison to Agarwal et al.’s (2020) study, Lin et al. (2018) also complement the prior study’s results with the perspective of caregivers. Lin et al. (2018) examine the helpfulness of involving patient caregivers in a discharge planning program and how it affects the caregiver burden level for patients with schizophrenia. The study involves caregivers through needs assessment tools, providing and connecting them with resources in the community, education on their family’s mental health, and assessment of the caregivers’ own level of stress and health status. The study shows that although there is a form of respite for caregivers when their loved ones are admitted into the hospital, involving them in discharge planning proves effective in terms of decreasing their own caregiver burden levels and improving their ability to better take care of their family once they are discharged from the hospital. This adds an element of aid to decrease the patient’s chance of being readmitted to the hospital as well as provides a counter to the disadvantages of caregivers previously identified by Beckner et al. (2021). Prusaczyk et al.’s (2019) study also supports this finding with the same results involving a decrease in caregiver burden through education on discharge planning with their families with dementia. Lastly, Baksi et al. (2021) recommend from their study findings that it is important for the health care team to involve patients’ families and caregivers in discharge planning (e.g., providing education materials such as brochures, videos, and pamphlets) as it helps patients feel confident and ready for hospital discharge. Assisting nurses with discharge planning involves the provision of proper education for better delivery of knowledge during the discharge planning process. In order to have a successful discharge with a lower risk of hospital readmission, nurses need to have proper training and education but also have the knowledge of resources to recommend to patients and their caregivers. It is also important for nurses to know when it is appropriate to involve the multidisciplinary team (e.g., occupational therapy team) to better prepare the patient for discharge and the importance of caregiver involvement for the patient’s successful transition to their home.



Significance and Justification

Findings from the initial literature review reveal that a lack of knowledge exists in nursing and patient care practice regarding discharge planning. Due to the nature of nursing workload, discharge planning tends to be seen as a low priority among other tasks (Davisson & Swanson, 2020b). The study by Davisson and Swanson (2020b) shows that although nurses in the sample see discharge planning as unstructured, they also understand its importance. The nurses in the study understand that proper discharge planning helps prevent hospital readmission. Yet there are barriers such as time constraints and lack of discharge timeline communication that cause a lack of discharge education, let alone planning. Hence, the need for a resource guide that can be used by nurses to start discharge planning from the moment of admission in the hospital setting. In order to identify a patient’s needs at discharge, it is important for the nurse to have knowledge of a patient’s pre-hospitalization capabilities at home. This can potentially cause a ripple of involvement with other multidisciplinary teams who can assist in helping to prepare patients for their eventual discharge. This project is necessary because it can help provide nurses a more structured discharge plan that is ongoing throughout a patient’s hospital admission regardless of a possible increase in a patient’s acuity or need for medical intervention.



Project Objectives

The objectives of this project are to:

1. Conduct an extensive review of the literature exploring discharge planning using the following keywords both singularly and in multiple combinations: discharge planning, nursing, research, study, elderly, discharge preparedness, community nursing, and
selfcare. Databases searched, limited to the years 2017 and 2022, will include, CINAHL Plus with Full Text, EBSCO, Google Scholar and the D’Youville library to loan articles through interlibrary loan;

2. Develop a resource guide; and

3. Have a panel of five content experts with extensive knowledge and expertise in discharge planning evaluate and critique the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.


Definition of Terms

The following concepts are defined both theoretically and operationally for the purpose of this project:

Caregivers

Theoretical Definition: People who assist a patient who is unable to manage their own health care needs independently (Schreiner & Daly, 2020).

Operational Definition: A patient’s family, friend, or health care provider that provides support and assists them in managing their health care or activities of daily living.

Discharge Planning

Theoretical Definition: A process that needs to be started at the beginning of a patient’s hospital admission in order to organize the essential preparations needed for patients to safely continue their care at home (Hayajneh et al., 2020).

Operational Definition: A part of nursing duty that starts with the assessment of a patient’s capabilities and functions at home. This is ongoing throughout the patient’s hospital admission and requires collaboration from the health care team with the goal of preventing hospital readmission.


Limitations

The Project Author recognizes the following project limitations:

1. The implementation of the resource guide is not within the context of this project;

2. The resource guide is developed in the English language only and may benefit a more culturally diverse population if written in additional languages


Project Development Plan

A detailed topical outline of the resource guide content is created based on the extensive review of evidence-based literature and the theoretical framework used to support and guide the development of the resource guide. After permission is granted from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in discharge planning will be asked if they are interested in voluntarily participating as an expert content reviewer for the resource guide. The content expert panel will consist of three registered nurses, and two coordinators with discharge planning responsibilities. If interested, the Project Author will mail a packet containing a Letter of Intent (Appendix B), a copy of the Content Expert Project Evaluation Tool created by the Project Author specifically for the project (Appendix C), a copy of the resource guide (Appendix D), and a self-addressed stamped envelope. The Letter of Intent will explain the project purpose and instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author. The Content Expert Project Evaluation Tool contains six evaluative items with space for narrative comments and suggestions. Approximately 20 minutes will be required to review the resource guide and to complete the Content Expert Project Evaluation Tool. Content experts will be provided a self-addressed envelope to return the Content Expert Project Evaluation Tool to the Project Author. Once all evaluation tools are returned to the Project Author, data will be analyzed and reported narratively and in bar graph format. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tool will be provided to the content expert reviewers by postal mail.


Plan for the Protection of Human Subjects

Following approval from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in the field of discharge planning will be personally approached and asked to voluntarily participate as a content expert in the review and evaluation of the resource guide (Appendix D). Content experts will be advised that participation or non-participation as an expert reviewer will have no effect on their employment status. The Project Author has a collegial, professional, and nonsupervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. Content experts will be guaranteed confidentiality because identifying characteristics will not be collected on the Content Expert Project Evaluation Tool and because their names will not be revealed anywhere in the project manuscript or in required project presentations. Only the Project Author will know the names of the content expert reviewers. Return of the completed content expert Project Evaluation Tool (Appendix C) will indicate implied voluntary consent to participate as a content expert reviewer. Content experts will be advised that they will not be able to withdraw from project participation once the project evaluation tool is returned to the Project Author because the evaluation tool will be returned without identifying information. Returned Content Expert Project Evaluation Tools will be stored according to the D’Youville Patricia H. Garman School of Nursing protocol in a locked

drawer located in the Project Author’s home for a period of six years and then destroyed.


Plan for Project Evaluation

After obtaining full approval from the D’Youville Patricia H. Garman School of Nursing (Appendix A), the Project Author will mail a packet to each content expert reviewer containing one Letter of Intent (Appendix B), one copy of the Content Expert Project Evaluation Tool (Appendix C), one copy of the resource guide (Appendix D), and one self-addressed stamped envelope. The Letter of Intent will explain the project purpose and instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author.

The Content Expert Project Evaluation Tool will consist of six evaluative items scored on a four point Likert Scale that ranges from (1) Strongly Disagree, (2) Disagree, (3) Agree, and (4) Strongly Agree. Space will be provided for narrative comments and suggestions following each evaluative item. Evaluative items will ask reviewers to rate the resource guide on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.

Approximately 20 minutes will be required to review the resource guide and to complete the Content Expert Project Evaluation Tool. Content experts will be given seven days to complete and return the Content Expert Project Evaluation Tool to the Project Author via postal mail using the self-addressed stamped envelope included in the original packet. Likert scale responses will be presented narratively and displayed in bar graph format. Content expert suggestions and comments will be analyzed for common themes and presented narratively. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tool will be provided to the content expert reviewers by postal mail.


Summary

Chapter I presented the project introduction, statement of purpose, an overview of the theoretical framework guiding project development, an initial review of the literature focusing on the development of a resource guide for nurses in the hospital setting to identify the patient’s needs at discharge, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II will provide an extensive review of the literature focusing on the development of a resource guide for nurses in the hospital setting to identify the patient’s needs at discharge and a chapter summary. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future projects and research, and a chapter summary.

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Orem, D. E., Renpenning, K. M. L., & Taylor, S. G. (2003).
Self care theory in nursing: Selected papers of Dorothea Orem. Springer Pub.

Popejoy, L. L., Vogelsmeier, A. A., Wang, Y., Wakefield, B. J., Galambos, C. M. & Mehr, D. R.

(2021). Testing re-engineered discharge program implementation strategies in SNFs.
Clinical Nursing Research, 30(5), 644-653.

Popejoy, L. L., Wakefield, B. J., Vogelsmeier, A. A., Galambos, C. M., Lewis, A. M., Huneke, D., Petroski, G. & Mehr, D. R. (2019). Reengineering skilled nursing facility discharge:

Analysis of reengineered discharge implementation.
Journal of Nursing Care Quality, 35

(2), 158-164.

Prusaczyk, B., Olsen, M. A., Carpenter, C. R. & Proctor, E. (2019). Differences in transitional care provided to patients with and without dementia.
Journal of Gerontological Nursing, 45 (8), 15, 24.

Schreiner, N. & Daly, B. (2020). A pilot study exploring treatment burden in a skilled nursing population.
Rehabilitation Nursing, 45 (3), 158-165.

Scott, C., Andrews, D., Bulla, S. & Loerzel, V. (2019). Teach-back method: Using a nursing education intervention to improve discharge instructions on an adult oncology unit.

Clinical Journal of Oncology Nursing, 23 (3), 288-294.

Tawalbeh, L. I., Al-Smadi, A. M., AlBashtawy, M., AlJezawi, M., Jarrah, M., Musa, A. S. & Aloush, S. (2020). The most and the least performed self-care behaviors among patients with heart failure in Jordan.
Clinical Nursing Research, 29 (2), 108-116.

Verna, E. C., Landis, C., Brown Jr., R. S., Mospan, A. R. Crawford, J. M., Hildebrand, J. S., Morris, H. L., Munoz, B., Fried, M. W. & Reddy, K. R. (2022). Factors associated with readmission in the United States following hospitalization with coronavirus disease 2019.

Clinical Infectious Disease, 74 (10), 1713-1721.

Whitehouse, C. R., Long, J. A., Maloney, L. M., Daniels, K., Horowitz, D. A. & Bowles, K. H. (2020). Feasibility of diabetes self-management telehealth education for older adults during transitions in care.
Research in Gerontological Nursing, 13 (3), 138-145.

Yen, H., Lin, S. & Chi, M. (2022). Exploration of risk factors for high-risk adverse events in elderly patients after discharge and comparison of discharge planning screening tools.

Journal of Nursing Scholarship, 2022 (54), 7-14.

Appendix A

Patricia H. Garman School of Nursing

Full Approval Letter

Appendix B

Letter of Intent

Content Expert Letter of Intent

Dear Content Expert,

Hello, my name is nixxkkk I am a graduate student completing a Master of Science in nursing degree at D’Youville College in Buffalo, New York. Currently, I am developing a resource guide for nurses in the hospital setting.

I am submitting the resource guide for your expert review and evaluation. Recommendations and critique of this work in progress will be taken into serious consideration during the final revisions of this work. You are being asked to review and evaluate the resource guide for clarity, readability, applicability, quality, organization, and evidence-based relevance. Your review of the resource guide should take approximately 20 minutes of your time. The evaluation process is completely voluntary and your refusal to participate will involve no penalty or loss to you. Your responses will be kept confidential and will be available only to me. If you choose to participate, please return the evaluation tool within the next seven (7) days using the enclosed self-addressed stamped envelope. Consent to participate in the evaluation is implied upon the completion and return of the evaluation tool. Once you return the evaluation tool, there is no way to withdraw your responses, as there are no identifying markers included on the tool. Returned evaluation tools will be stored in my home for a period of six years and then destroyed. There are no direct benefits to you as a content expert participant. A copy of the results including the findings of the six evaluative items in the content expert project evaluation tool will be mailed to you at the conclusion of this project.

If you have any questions regarding my project or the evaluation process, please contact me via email at nixxxkk. Any specific questions may be directed to _____, my Project Chair, at (716) ____ or via email at____. Thank you for your assistance and participation as a content expert. I look forward to receiving your evaluation of my project.

Best Regards,

Appendix C

Content Expert Project Evaluation Tool

Instructions:

The purpose of this tool is to provide you with a guideline for evaluating the clarity, readability, applicability, quality, organization, and relevance to current evidence-based practice of the proposed resource guide. The purpose of the project is to develop a resource guide to provide nurses information on discharge planning in the hospital setting. Using the four point Likert Scale, please circle one choice that best reflects your opinion. Space is provided after each of the six evaluative items for further feedback and direction regarding the resource guide. To maintain your confidentiality, please do not make any identifying marks on the evaluation tool.

1. Clarity

The information presented in the resource guide is clearly understood and easy to follow.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

2. Readability

The information in the resource guide is presented at an appropriate and comprehensive level of reading for nurses in the hospital setting.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

3. Applicability

The information presented in the resource guid

e is relevant and fits the project purpose.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

4. Quality

The resource guide is well designed and professionally presented.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

5. Organization

The resource guide is logical in order and well organized.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

6. Evidence-Based Clinical Relevance

The resource guide addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence.

Strongly disagree

Disagree

Agree

Strongly agree

1

2

3

4

Comments and Suggestions:

Thank you for taking time to evaluate the resource guide. Your feedback is deeply appreciated and will strengthen the development of the resource guide for nurses in the hospital setting.

Appendix E

Survey Tool Results

EDUCATIONAL TRAINING PROGRAM FOR NURSES IN AN OUTPATIENT SETTING TO PROVIDE EDUCATION REGARDING THE IMPORTANCE OF A HEALTHY DIET FOR PATIENTS WITH OBESITY.

By

Student name

A Project

Submitted to the Faculty Name in partial fulfillment of the requirements for the degree of

Course

in

Unit

Buffalo, NY

[Month day, year]

Copyright © 2022 by Student name. All rights reserved. No part of this project may be copied or reproduced in any form or by any means without the written permission of STDENT NAME

2

PROJECT APPROVAL

Project Committee Chairperson

Name:
__ ____________________________________________________

Signature: ___________________________________________________

Discipline:
___________________________________________________

Project Defended

On

[Month Day, Year]

Abstract

Obesity has become a significant concern in the healthcare system, and diet is the key contributing factor to obesity. Therefore, a healthy diet should be the primary requirement in reducing weight and improving overall health. The health life knowledge gap among patients and limited nursing education programs contribute to this condition. Nurses should work closely with patients to provide healthcare education that will help patients improve their nutrition habits and identify the challenges the patients face in maintaining a healthy diet. An education training program for nurses in outpatient settings regarding obesity and diet will allow nurses to advance their knowledge on the risk factors of obesity, the health conditions associated with obesity, and how to manage obesity (Mitchell et al. 2018).

Acknowledgment

[Inclusion of an acknowledgment page is optional. The student should seek guidance from the project director on whether to include the page in the final project manuscript. If it is included, it is numbered as page Roman numeral v, each paragraph is indented five spaces (1/2”), and the text is double-spaced. This page is placed just after the Abstract and just before the Table of Contents.]

Table of Contents

Chapter

I. PROJECT INTRODUCTION …………………………………………………………… 1

Statement of Purpose ……………………………………………………………………….. 2

Theoretical Framework ……………………………………………………………………. 2

Initial Review of the Literature …………………………………………………………. 9

Significance and Justification ……………………………………………………………. 9

Project Objectives …………………………………………………………………………. 11

Definition of Terms ……………………………………………………………………….. 11

Project Limitations ………………………………………………………………………… 14

Project Development Plan ………………………………………………………………. 15

Plan for Protection of Human Subjects …………………………………………….. 16

Plan for Project Evaluation……………………………………………………………… 17

Summary ……………………………………………………………………………………… 17

II. REVIEW OF LITERATURE ………………………………………………………….. 19

Summary ……………………………………………………………………………………… 30

III. PROJECT DEVELOPMENT PLAN. ………………………………………………. 39

Project Setting and Population… …………………………………………………….. 39

Content Expert Participants …………………………………………………………….. 39 Data Collection Methods ………………………………………………………………… 39

Project Tools ………………………………………………………………………………… 40

The Protection of Human Subjects ……………………………………………………… 41

Summary ……………………………………………………………………………………… 42

IV. PROJECT EVALUATION, IMPLICATIONS, AND FUTURE RECOMMENDATIONS

…………………………………………….. 44

Project Evaluation …………………………………………………………………………. 44

Implications for Future Practice ………………………………………………………. 46

Future Recommendations ……………………………………………………………….. 48

Summary ……………………………………………………………………………………… 50

References ……………………………………………………………………………………. 51

Appendices …………………………………………………………………………………… 60

7

List of Appendices

Appendix

A D’Youville Patricia H. Garman School of Nursing Full Approval Letter

…………………….…. 60

B Letter of Intent ……………………………………………………………………………………. 62

C Evaluation Tool ………………………………………………………………………………….. 64

D Product ……………………………………………………………………………………………… 66

E Survey tool results in graph……………………………………………….

Chapter I

The age of fast food and instant gratification brought about by the growth of technology has affected the general population in many ways In America, obesity is becoming problematic with a prevalence estimate of 41% leading to risk in severity of diseases (Kalligeros et al., 2020). As a result, there is a need for nursing practice to take accountability in developing a relationship with collaborative patient care. Obesity can be a lifestyle disease. Therefore, all stakeholder participation must be considered a need to look at the four-metaparadigm perspectives in caregiving using a foundational basis in a theoretical framework. For this study, interpersonal relations in nursing theory will be discussed.

ADD MORE STUFF HERE……..



Statement of Purpose


The purpose of this project is to develop an educational training program for nurses in an outpatient setting to provide education regarding the importance of a healthy diet for patients with obesity.



Theoretical Framework

Should start like this —-Dorothea E. Orem’s (1991) self-care deficit nursing theory is utilized as the theoretical framework for the development of this project. A brief overview of the theory is presented as well as a discussion regarding how the theory was utilized to guide the development of the project. In addition, Orem’s (1991) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definitions for nursing’s four metaparadigm concepts will be presented.

(
source, year, page). The theoretical framework section should be a minimum of 3 pages in length. This section should be presented as follows:

Not like this- please change the format- Many theories support the understanding of nursing concepts and thus form the basis and foundational elements of patient care. Interpersonal Relations in Nursing Theory is a theory formulated by a female nurse, Hildegard Peplau. Within the theory, Peplau describes the metaparadigm concept of nursing within the four sequential interpersonal relationships. They are foundational elements as orientation, identification, exploitation, and resolution defined within nurse, health, patient, and environments aspects of nursing healthcare provision. “As such, the theory emphasizes the importance of crosscutting issues and their effect on nursing care and patient wellness (Peplau, 2004).” (“The purpose of this project is to develop an educational training …”)

It thus facilitates better planning to understand the complexities of issues underlying the patient’s conditions, which would hinder getting well. In recognition of this, this paper aims to bring to attention the definition of the metaparadigm concept of patient care within this theory by looking at its significance and interpersonal relationship as contextualization in patient care. At the same time, the paper will look at its actual application as employed in modern nursing care as a mainstream cultural competency component. The deliberate look of this theory within this aspect will facilitate a conclusion on the modern-day emphasis and necessitated patient-centered model of care.


Significance of Interpersonal Relations Nursing Theory

As a mother of nursing psychiatry, Peplau (2004) describes interpersonal relations as a conditional aspect that includes first the interaction of the nurse and patient. She points out that this is attained when understanding each patient’s condition is an experience that allows for improving nursing care (Peplau, 2004, p. x). Therefore, the focus in the definition of the theory begins with grasping the nurse and patient metaparadigm concepts as the interaction between patient and nurse makes the relationship personal. Similarly, considerable insights thus point out that the patient care process is personalized in a way that responsibility is both technical and emotional. Peplau (2004) explains that effective patient outcome delivery comes from trust in diagnostics and thus acceptance of health as an essential metaparadigm aspect. The theory focuses on the development of the relationship between a nurse and a patient in a way that emphasizes trust and collaboration. It is therefore a good fit for my topic as the relationship between outpatient and the nurse must be founded on trust so that information can be shared in comfort and with trusted support to be present. Based on the fact that obesity and issues surrounding obesity could often bleed into self-esteem and mental health, it is essential that a support system is developed well, a foundation that this theoretical framework supports.


Metaparadigm Concepts in Interpersonal Relations Nursing Theory

Thus, nursing can be defined based on culture and concrete work (Peplau, 2004, p. 5). Thus, it promotes health through appropriate methods and illness prevention by recognizing triggers for all patients
(A second theory from a discipline outside of nursing such as sociology, education, or management non-nursing theorist may also be used. you cannot use this; must be Peplua only-Riekert, 2021). Therefore, the nurse can only facilitate treatment and not make a diagnosis; hence, the critical aspect is ensuring that the environment is conducive and that communication in the relationship with patients is constant. This means the nurse favors patients’ understanding of their issues by explaining the problem and the treatment plan. This includes a preventive measure to ensure informed decision-making is enhanced and thus a partnership that, in essence, is therapeutic.

According to Okdie et al., (2018), communicative action between in the digital age between nurse and patient is a bold navigation of interpersonal relationships. The increase ins tendency of maintenance takes a newer approach as infromation overload can be present due to media. This could be advantageous for outpatient care but also the opposite is true. As such, following Peplau’s underpinning of patient care, nursing is the implementation of need-based healthcare delivery through the respectable promotion of perception and prevention of escalation of illness (Peplau, 2004, p. 9). Therefore, it can be said that the operational definition of nursing is ensuring that patient needs are met adequately and suitably hence unique to the patient. With that, a different relationship develops between nurse and patient.

In recognition, a person is operationally defined as an entity with individual preconceptions and mutual understanding of the nature of a medical issue and collaborates towards a productive solution. Therefore, this contextualizes the environment as conditions that allow for human processes that facilitate tendencies supportive of positive development to attain health (Peplau, 2004, p. 12). By this definition, health can operationally be defined as a symbolic future positive goal that is attained after effective healthcare hence instrumental for the person moving in the forward direction of wellbeing (Peplau, 2004, p. 13).

Initial Review of the Literature

Use this format- even though I did over my self- A review of nursing and health related literature was (the initial review of literature has been conducted so in this section, you can write in past tense) conducted to explore (project area of interest) using the following keywords both singularly and in multiple combinations:
,
,
. Databases searched, limited to the years
to
, included AMED, Alt Health Watch, CINAHL Plus with Full Text, and EBSCO. The search was limited to the years to
to ensure that current evidence-based literature was reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.




MUST BE FIRST PARAGRAPH-The review of the literature will be conducted to explore studies that are associated with nursing education for obesity and healthy diet. Using following words both singularly and in multiple combinations: nursing training, obesity, outpatient care, nursing psychiatry, overweight, diet, obesity facts, obesity prevention, body weight, and care management planning. Databases searched, limited to the year 2017 and 2022, will include AMED, Alt Health Watch, CINAHL Plus with Full Text, and EBSCO, Medical Journal sites for nursing care, nursing training, PubMed, Scopus, Science Direct, Directory of Open Access Journals, Google Scholar, and JSTOR. The search is limited to the years 2017 to 2022 to ensure that current evidence-based literature is reviewed and summarized for the purpose of this project. A summary of the literature is presented in this section.

Dynamics of Outpatient Care

Critical to the discussion on nursing care for outpatient with obesity is the fact that it is a lifestyle disease. As such, the focus of care is strongly on management and fostering better and healthy weight maintenance (Kalligeros et al., 2020). It thus does not necessarily focus on age but understands that eagerness is also a risk factor in getting comorbidities associated with being overweight. Kalligeros et al. (2020) study point out that the exploration of the association between obesity and chronic diseases is something that should be understood. This is because there is a direct relation between the severity of the outcomes that are seen in intensive care units and admission rates. Using analysis of a retrospective cohort with 103 patients, the research found out that of the patients that are admitted to the hospital history of heart disease is a direct result of obesity. Therefore, there is a recommendation that vigilance should be given to the treatment of patients with obesity alluding to necessitated prevention of escalation when faced with other conditions (Kalligeros et al., 2020).

Role of Nursing

This is supported by Rezaei, et al. (2022) study that points out the fact that high morbidity rates are caused by poor health maintenance. The fact that the high number of obesities creates a risk factor in the population that carries it points to a need to emphasize the training for this. As such, recognition of physician effort in collaboration with outpatient by sensitization on environmental awareness is essential (Walia et al., 2022). This includes considering that proper evaluation starts by recognizing the appropriateness of the environment for supporting weight management. Achieving and maintaining weight loss or gain requires that there is physician-patient collaboration in a way that can be facilitated by nurses providing proper information. Support and motivation also are determined by letting a carefully defined plan be identified together with the patient to understand the health outcomes expected. This is the work of the nurse as it allows for the recognition of strategy of control for each different patient.

According to Rezaei et al. (2022), the combination of aspects such as cost of health, care expenditures, and hospitalization risks are some of the reasons that can be used in motivating outpatients to adhere to their plan of losing weight. Advanced heart diseases are often caused by obesity and lack of maintenance and within that determinant of failure lies in early handling of the issue. Health literacy is an important part of the nursing fraternity to impart to the patients as it allows for the opportunity to understand the implication of obesity in the long run. This is especially true because by the time medication is involved, the progression will be higher risk associated and thus significant mortality risk. Health literacy as part of outpatient training will not only provide the necessary support for proper weight loss but also in maintaining it while allowing room for recognition of mental health too. This caters to the grasping of the incorporation of strategies that align outcomes centered on the totality of patient care within the six sigma of quality improvement in healthcare delivery (Alexander et al., 2021).

Alexander et al., (2021) research look into the focus of promotion of healthcare delivery as a focal point in preventive care. The research looks at transitioning patients from outpatient to inpatient and within this provides insight on what to avoid and what is necessary to promote better care. Right from the start the research allows room for relativity in practices that promotes and optimizes safety, and within those points to the relevance of patient individual circumstance. While the paper stick to giving valuable information on the standard procedure, it contributes to the discussion on the improvement of health by nurses in general. It thus applies that, for all patients, recognition of the value in situation background assessment facilitates the improvement of health outcomes. The improvement starts with a reduction in risks hence understanding beneficial outcomes accurately first (Alexander et al., 2021).

Recognition of Potential Barriers

Categorically, there is also a need to recognize the degree of the impact of cultural competency within nursing care (Chae & Park, 2019). With outpatients, there is a risk of exposure to external biases and pressure that may result in declining health whenever they leave a session. Therefore, the value must be provided in educating the patient on the potential risks that they face within their environment. This can only be achieved through collaboration. It is important for the perspective of the community and support system that is there for the patient to be observed by the patient (Ogbolu et al., 2018). Therefore, sharing with the nurse is a natural step of goal setting that allows an informed understanding of the underlying implication of the stereotypes and norms of expectation (Halvorson et al., 2019). This will help in focusing on reducing the risk of “temptation” of hindrances to the improvement of patient health in a way that respects both them and their communities. Planning is an essential tool that both the nurse and the patient should recognize early on.

It is especially important when it comes to the management of unvoiced expectations of a patient in a way that recognized their efforts and their input towards change. Being a lifestyle disease, obesity management requires self-discipline at a higher level than normal and within that recognition of a result that is gradual (Ma et al. 2019). The fact that it cannot be cured by medication and results are not immediate is a cause of concern that should be understood by both nurse and patient. This requires patience and a lens where competent management can only be weighed by the small milestones.

Similarly, when optimization of management is a need in the treatment strategy for a patient with obesity, especially outpatients, there is a need for longitudinal consideration of the comprehensiveness of management aspects. According to Seger (2019), a complication of obesity as a chronic illness is as sophisticated as any other issue. As such, there is an intensity level that should be employed with preventive controls active in line with the responsibility set. This allows for desired treatment to be the main goal rather than the desired end product such as specific weight. It removes eth tension without negating the implication of the process and thus optimizes input by the small measures that can be seen regularly. A pathophysiological approach is necessary for an all-hands-on methodology hence simplicity that is specific to the patient in question rather than a generalization (Block et al., 2020).
And this is too short,, please add more; you have to compare and contrast the studies, you have to use all the 20 reference here, and must use transitional phrases.



Significance and Justification

Find one study from the literature review that support the subject and Start like this Findings from the initial literature review reveal that a lack of knowledge exists in nursing and patient care practice regarding…

Then you talk about the article you chosen; you have included the sentence based on how the literature support the project purpose.

WriteWhy do you feel this article is a good choice for supporting your proposed project?

WE STOP HERE FOR NOW….

6. Instructions for the Project Objectives section -SINGLE SPACE AND INDENTED

The Project Objectives section follows the Significance and Justification section and is written in the present tense. Project objectives identify at least 3 specific outcomes (aims/goals) describing what the student hopes to accomplish by carrying out the project. All educational projects require students to 1) conduct a review of the literature exploring the background of the project topic/problem/issue; 2) develop and/or create a product such as an educational program, workshop, PowerPoint, or video, an interview schedule, questionnaire or survey, a professional brochure or pamphlet, or a handbook or resource guide; and 3) have the project product evaluated/reviewed by a panel of content experts who have extensive knowledge and expertise in the project area of focus.

Project Objectives

The objectives of this project are to:

1. Conduct an extensive review of the literature exploring (project area of interest) using the following keywords both singularly and in multiple combinations:
, ,
. Databases searched, limited to the years
to
, will include AMED, Alt Health Watch, CINAHL Plus with Full Text, and EBSCO Host;


SINGLE SPACE FOR THIS SECTION



Project Objectives

The objectives of this project are to:

1. Conduct an extensive review of the literature exploring discharge planning using the following keywords both singularly and in multiple combinations: discharge planning, nursing, research, study, elderly, discharge preparedness, community nursing, and
selfcare. Databases searched, limited to the years 2017 and 2022, will include, CINAHL Plus with Full Text, EBSCO, Google Scholar and the D’Youville library to loan articles through interlibrary loan;

2. Develop a resource guide; and

3. Have a panel of five content experts with extensive knowledge and expertise in discharge planning evaluate and critique the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.



Definition of Terms

References

Kalligeros, M., Shehadeh, F., Mylona, E. K., Benitez, G., Beckwith, C. G., Chan, P. A., & Mylonakis, E. (2020). Association of obesity with disease severity among patients with coronavirus disease 2019. 
Obesity
28(7), 1200-1204.

Peplau, H. (2004).
Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. Springer Publishing.

Riekert, S. A. (2021). The Home Healthcare Nurse: A Concept Analysis. 
Home Healthcare Now
39(4), 194-202.

Ogbolu, Y., Scrandis, D. A., & Fitzpatrick, G. (2018). Barriers and facilitators of care for diverse patients: Nurse leader perspectives and nurse manager implications. 
Journal of nursing management
26(1), 3-10.

Okdie, B. M., & Ewoldsen, D. R. (2018). To boldly go where no relationship has gone before: Commentary on interpersonal relationships in the digital age. 
The Journal of social psychology
158(4), 508-513.

Ma, J., Rosas, L. G., Lv, N., Xiao, L., Snowden, M. B., Venditti, E. M., … & Lavori, P. W. (2019). Effect of integrated behavioral weight loss treatment and problem-solving therapy on body mass index and depressive symptoms among patients with obesity and depression: the RAINBOW randomized clinical trial. 
Jama
321(9), 869-879.

Seger, J. C. (2019). Optimizing Outcomes in Outpatient Obesity Management. In 
Quality in Obesity Treatment (pp. 221-234). Springer, Cham.

Halvorson, E. E., Curley, T., Wright, M., & Skelton, J. A. (2019). Weight bias in pediatric inpatient care. 
Academic pediatrics
19(7), 780-786.

Chae, D., & Park, Y. (2019). Organisational cultural competence needed to care for foreign patients: A focus on nursing management. 
Journal of Nursing Management
27(1), 197-206.

Wood, D. A., Mahmud, E., Thourani, V. H., Sathananthan, J., Virani, A., Poppas, A., … & Krahn, A. D. (2020). Safe reintroduction of cardiovascular services during the COVID-19 pandemic: from the North American Society Leadership. 
Journal of the American College of Cardiology
75(25), 3177-3183.

Oleck, L. (2022). Psychiatric-Mental Health Nurses: Spread the Word!
Journal of the American Psychiatric Nurses Association, 28(5), 413–415.
https://doi.org/10.1177/10783903221117555

Whitehouse, C. R., Sharts-Hopko, N. C., Smeltzer, S. C., & Horowitz, D. A. (2018). Supporting transitions in care for older adults with type 2 diabetes mellitus and obesity. 
Research in gerontological nursing
11(2), 71-81.

Rezaei, S., Vaezi, F., Afzal, G., Naderi, N., & Mehralian, G. (2022). Medication Adherence and Health Literacy in Patients with Heart Failure: A Cross-Sectional Survey in Iran. 
HLRP: Health Literacy Research and Practice
6(3), e191-e199.

Walia, I., Krainovich-Miller, B., & Djukic, M. (2022). Nurses’ Lived Experience With Nurse–Physician Collaboration. 
The Journal of Continuing Education in Nursing
53(9), 397-403.

Scott, J., McMillian-Bohler, J., Felsman, I., & Koch, A. (2022). Learner Response to an Activity Introducing Adverse Childhood Experiences as a Social Determinant of Health. 
Journal of Nursing Education, 1-4.

Phillips, K. E., & LoGiudice, J. A. (2020). Practices and Attitudes of Nursing Students Toward Patients with Disordered Eating Behaviors. 
Nursing education perspectives
41(1), 49-51.

Tartavoulle, T., & Landry, J. (2021). Educating Nursing Students About Delivering Culturally Sensitive Care to Lesbian, Gay, Bisexual, Transgender, Questioning/Queer, Intersex, Plus Patients: The Impact of an Advocacy Program on Knowledge and Attitudes. 
Nursing Education Perspectives
42(4), E15-E19.

Alexander, C. C., Tschannen, D., Hays, D., Clouse, M., Zellefrow, C., Amer, K. S., … & Milner, K. A. (2022). An integrative review of the barriers and facilitators to nurse engagement in quality improvement in the clinical practice setting. 
Journal of Nursing Care Quality
37(1), 94-100.

Alexander, C., Rovinski-Wagner, C., Wagner, S., & Oliver, B. J. (2021). Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff. 
Journal of Nursing Care Quality
36(3), 195-201.

Block, B. L., Smith, A. K., & Sudore, R. L. (2020). During COVID‐19, outpatient advance care planning is imperative: We need all hands-on deck. 
Journal of the American Geriatrics Society.

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