NKU: DNP-PROGRAM
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Module 6: Assignment — Construction of Clinical/Practice Question and Literature
Requires 8 full pages and 10-12 references within the last 5 years only.
SEE FULL DETAILS ATTACHED
Prompt:
The purpose of this assignment is to state your clinical/practice question and explore the literature pertaining to your clinical/practice problem as you described in your Module 3 Discussion Board . According to Moran et al. (2020) when conducting a literature review, the goal is to obtain a representative sample of the literature which describes the concepts related to the phenomenon of interest and the research results applicable to the clinical/practice question and identify what gaps need to be further researched.
Instructions:
1. Please follow the rubric ATTACHED.
2. Your work may be used to build upon your scholarly project and publishable manuscript—thus it is important that you align your literature review with the topic you have selected (or are considering) for your PICOT question and DNP project.
3. Length is no more than 8 pages excluding references and title page.
Exemplars—-I am providing 2 exemplars for you to view. Neither of these are perfect, nor did either earn 100%. However, each one is excellent. These exemplars are shared just for you to ‘see’ what your work might ‘look’ like. Please note that you must write according to APA…this is a format as well as a method for citing and referencing. In the grading rubric, please also see that 30 points are allotted to the writing at graduate level.
Construction of Clinical/Practice Question and Literature Review
Component |
Points |
Comments |
Points Achieved |
Section I Introduction and Question |
|||
A. Describe the clinical or practice problem you would like to address for your DNP project. State why this problem is an issue. Support your reasoning/rationale as to why this is an issue with current data or literature. (3 of the 6 points) B. State the practice question you wish to address in PICOT format (this should be the response to the problem defined above). (3 of the 6 points) |
6 |
||
State the population and setting being addressed |
2 |
||
Introduction to the Literature Review on the topic |
2 |
||
Section II Review of Literature |
|||
Includes most of the |
10 |
||
Includes primarily research studies, systematic reviews and guidelines addressing the practice question you wish to address |
10 |
||
Similar/discrepant research findings discussed |
5 |
||
Section III Appraisal and Synthesis |
|||
Critically appraises the contributions of key studies and provides the strengths of the evidence |
5 |
||
Describes the weaknesses in existing studies and identifies important gaps in the literature |
5 |
||
Conceptually organized based on type of articles or findings |
5 |
||
Succinctly summarizes and synthesizes findings |
15 |
||
Section IV Further Research |
|||
Identifies what ideas need to be further researched |
5 |
||
Preparation—The DNP Program Evaluation Rubric for Papers will be followed to assess Preparation of this Review of Literature. See the Rubric for Papers below. This is a total of 30 points. |
30 |
||
Total Assignment Grade |
100 |
||
Professor Comments: |
CRITERIA |
30 – 25 POINTS |
<25 – 15 POINTS |
<15 – 10 POINTS |
<10 – 5 POINTS |
<5 – 0 POINTS |
|
6-5 POINTS |
4-3 POINTS |
2 POINTS |
1 POINTS |
0 POINTS |
Points |
|
Thesis / Topic |
Exceptionally clear; easily identifiable, insightful; introduces the topic for the paper; summary in one or two well-written sentences. |
Generally clear; is promising; could be a little more inclusive of the content of the paper. |
Central idea is adequate but not fully developed; may be somewhat unclear (contains vague terms); only gives a vague idea of the content of the paper. |
Difficult to identify with inadequate illustration of key ideas; does not let the reader know what the paper is going to include. |
No thesis statement or introduction is identifiable. |
|
6-5 POINTS |
4-3 POINTS |
2 POINTS |
1 POINTS |
0 POINTS |
||
Content / Development |
Thesis coherently developed and maintained throughout; thorough explanation of key idea(s) at an appropriate level for the target audience; critical thinking with excellent understanding of the topic; original in scope (this paper made sense, was easy to understand, and did not leave reader with questions due to incomplete development). |
Explanation or illustration of key ideas consistent throughout essay; original but may be somewhat lacking in insight; minor topics of the paper could be developed more thoroughly. |
Explanation or illustration of some of the key ideas; reader is left with some questions due to inadequate development; content may be a little confusing or unclear as to what the author means. |
Little or no relevant detail; many areas that could be expanded. |
Paper does not make sense; unclear what the author is trying to say; very little real information presented. |
|
6-5 POINTS |
4-3 POINTS |
2 POINTS |
1 POINTS |
0 POINTS |
||
Organization |
Good organization with clear focus and excellent transition between paragraphs; logical order to presentation of information; paragraphs are well-organized; easy to understand and makes sense. |
Adequate organizational style with logical transition between paragraphs; overall or paragraph organization could be slightly improved. |
Adequate organizational style, although flow is somewhat choppy and may wander occasionally; somewhat confusing due to organization of paper or paragraphs. |
Incoherent structure; logic is unclear; paragraph transition is weak; difficult to understand; must re-read parts to figure out what is being said. |
No order to content; very confusing and difficult to read; makes no sense. |
|
6-5 POINTS |
4-3 POINTS |
2 POINTS |
1 POINTS |
0 POINTS |
||
Mechanics |
Skillful use of language; varied, accurate vocabulary; well-developed sentence structure with minimal errors in punctuation, spelling or grammar; appropriate margins, font; correct application of research style format; use of professional active voice; very well-written paper. |
Appropriate use of language with a few errors in grammar, sentence structure, punctuation; fairly accurate interpretation of assignment guidelines, with a few minor errors; |
Some |
Many difficulties in sentence structure, grammar, citation style, punctuation, spelling and/or misused words; proper format not used consistently |
Not written at a graduate level; many mistakes; proper format not used consistently |
|
6-5 POINTS |
4-3 POINTS |
2 POINTS |
1 POINTS |
0 POINTS |
||
References |
Uses sources effectively and documents sources accurately with minimal errors; limited use of direct quotes (No more than 2 or 3); meets reference requirements for assignment; reference list is in correct format. |
Appropriate sources and documentation; may have minimal errors with too few or too many in-text citations; missing no more than one reference as required for the assignment. |
Some quotes not integrated smoothly into text; several errors with in-text citations or reference list; omitted in-text citations infrequently; missing 2 required references; overuse of direct quotes |
Quotes are not well integrated into narrative or are significantly overused; paraphrasing is too close to original work. (Minimal errors only; more significant errors will be considered plagiarism – See Plagiarism statement to right.) |
Plagiarism – source material not adequately paraphrased; direct quotes not identified; source material not referenced. Papers will be given a grade of zero and could result in failure of the course |
|
Total Points: |
Running head: LITERATURE REVIEW 1
Construction of Practice Question and Literature Review
Student Name
Northern Kentucky University
LITERATURE REVIEW 2
Construction of Practice Question and Literature Review
This paper is the first step of the author’s scholarly project for the Doctor of Nursing
degree. The paper will state the practice question for scholarly project to be developed. This
paper will present a literature review of the available evidence within the last four years that
addresses the practice problem. Appraisal of some of the evidence will be presented. Exploration
of needed further research on the topic will also be discussed.
Introduction & Practice Question
The author’s scholarly project will be focused on the new graduated nurses and
confidence to advocate patient changes to the interprofessional team. All new graduates who take
the Registered Nurse National Council Licensure Examination are exposed to information about
patient advocacy and collaboration with the interdisciplinary team (NCSBN, 2016). Learning
about these concepts in a classroom is much different than application in a clinical setting. New
graduates must have confidence and be assertive when communicating a change in patient’s
condition to a health care provider. The author’s wants to implement a project that will assist new
nursing graduates to feel confident speaking up for patents.
The practice question asks, (P) In nurses working in an acute care setting and who have
graduated within the past 6 months (I) what is the effect of interprofessional patient simulation
(C) compared with no simulation on (O) increased confidence in communicating with health care
team members about patient changes (T) within the time frame of end of orientation, 6 months,
and one year?
The author searched for the knowledge regarding new graduate nurses’ confidence in the
ability to communicate with physicians. Literature was searched using Cumulative Index to
Nursing and Allied Health Literature (CINAHL), PubMed, and Google Scholar. Databases were
LITERATURE REVIEW 3
searched with using the terms new graduate nurses, patient simulation, physicians, confidence,
and also included several synonyms of the terms. These terms were searched using “AND” and
resulted in an initial finding of one article. A broad criteria was then adopted using terms in any
order or combinations to find articles that discussed new nurses and confidence with a focus on
situations with a physicians. Inclusion criteria was restricted to peer-reviewed, related to
experiences in nursing practice or transition to practice, and English language research between
2014 and 2018. Excluded any research that was focused on strategies only implemented in
nursing programs with students. A total of 25 abstracts were reviewed for relevance, 20 articles
were read for consideration and 7 was the total number of articles used in the literature review.
Review of Literature
New nurses reported that they lacked professional confidence at the beginning of their
career (Ortiz, 2016). New graduate nurses expressed the learning to challenge, speak up, is a
complex process that is dependent on experiences. When new graduate nurses did raise concerns
about a potential patient safety issues, there was a lack of responsiveness from other nurses and
superiors (Yee-Shuri Law, & Chan, 2015).
The historical role of nurses being subservient to physicians could lead to a lack of
assertive communication (Foronda, MacWilliams, & McAuthur, 2016). New nurses reported low
confidence about communicating with physicians. Berman et al., used a modified Casey-Fink
Graduate Nurse Experience Survey and found that the average score for confidence about
communicating with physicians as 2.73, with highest rating possible for an item as a 4 (2014).
Little to no interaction with physicians occurs as nursing students and can cause fear of
working with physicians. Difficult experiences were reported when communicating with
members of the interdisciplinary team with physicians who were not receptive to patient
LITERATURE REVIEW 4
advocacy (Ortiz, 2016). Fear can be increased with the witnessed abusive behavior of some
physicians toward other experienced nurses (Shatto & Lutz, 2017).
Simulation can be a highly successful method in building interprofessional
communication skills (Foronda, MacWilliams, & McAuthur, 2016; Salam, Saylor, &
Cowperthwait, 2014). Nurses and physicians reported strong positive attitudes supportive for
education to improve collaboration before interprofessional simulation with 26.3 % agreed and
73.7% strongly agreed; after the simulation experience, there was a statically significant shift
p=0.078 with 16.1% agreed and 83.9% strongly agreed (Salam, Saylor, & Cowperthwait, 2014).
New graduate nurses with simulation experiences during orientation reported an increase
in confidence that continued through 12 months post experience (Rhodes et al., 2016). According
to Rhodes et al., (2016), statistically significant increase in confidence scores occurred after a
simulation experience. Simulation is a tool that can be used for difficult situations that may occur
as a new nurse, especially a situation that requires working as a team and having crucial
conversations (Ortiz, 2016).
Appraisal and Synthesis
Appraisal
This author divided the evidence into subcategories by type in order to complete the
appraisal of the research. The evidence hierarchy from Polit & Beck (2017) was used for the
appraisal. The Critical Appraisal Skills Programme (CASP) checklist were used to appraise the
cohort study (2018). Guidelines from Polit & Beck (2017) were used to critique literature
reviews. Appraisal of surveys was completed with tool from Center for Evidence-Based
Management (2018). The qualitative studies were not appraised related to the page count
restriction for this assignment.
LITERATURE REVIEW 5
Cohort Study
Rhodes et al. (2016) is level 4 (Polit & Beck, 2017) prospective cohort study. The study
had a clear focus. A power analysis of n=72 was determined as an appropriate sample size. All
newly licensed registered nurses at the institution in the residency were required to participate in
the simulations, an initial and multidisciplinary. 93 new nurses participated in the residency at
the time of study. All of new nurses participated in the simulations and some were asked to
complete surveys prior to the simulation at baseline, post simulation, and six, twelve, eighteen
months post simulation. Completion of the surveys was considered consent. Content validity of
the measurement tools was completed. Possible confounding factors are not discussed in the
research or does this author believe it occurred. Highest response rates were from baseline and 6
months and decreased at 18 months. This author is not clear with the actual completion rate, but
from the result one can infer that the response rate may have dropped to 81%. The follow-up to
18 months does appear to be sufficient to measure the study outcome. Increases in knowledge
were modest from mean scores, was not statistically significant and this was confirmed with
Friedman test. Steady increase in mean scores for confidence measurements, and Friedman test
indicate statistically significant increases after initial simulation to 18 months. Multidisciplinary
training did not result in statistically significant confidence level changes. Wilcoxan signed rank
tests indicate statistically significant changes in satisfaction after simulations with the
multidisciplinary being highest. Confidence intervals are not present. Type II error is likely
related to decreased response rates and some with the data being underpowered. Results are
believable, but hard to clearly discern what the actual completion rates were for each survey
period. This results can be applied to other nurse residency programs with simulation
components. This author cannot comment if the results fit with other available evidence, since
LITERATURE REVIEW 6
other cohort studies were not found for this literature review. Results were used to modify the
institution’s nurse residency program, other practice implications were not discussed.
Surveys
Salam, Saylor, & Cowperthwait (2014) is a level 6 (Polit & Beck, 2017) cross-sectional
survey. The study is clearer focused on the issue and the study design is appropriate for the pilot
program. The participants came from three institutions to collaborate on this study. Selection bias
may be present, there is no discussion of randomization in the study. Participants are
representative of the population being studied. Participants include medical and nursing students,
residents, nurse interns, and faculty. Sample size was made up of 68 participants. The study does
not mention statistical power for appropriate sample size. A 96% survey completion rate was
achieved. The survey used a 4-point Likert scale to rate confidence of rating pain and also part of
the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration, these tools are likely to
be valid and reliable. Statistical significance was assessed and met with confidence after
simulation and in attitudes toward interprofessional collaboration. Confidence intervals are not
present. Person confounding is possible since students, residents, and nurse interns are all
included in the same sample. The results are applicable to practice when planning
interprofessional simulations.
Berman et al., (2014) is a level 6 (Polit & Beck, 2017) cross-sectional survey. The study
is focused on the competence gaps among new registered nurse graduates and research method is
appropriate. The process of selection of subjects is clearly described. Participants were total of
345 new graduates, from 23 different schools of nursing, enrolled in the program where the
surveys were administered. Selection bias is possible with a limited number of program spots
and there were at least three qualified applicants for every program spot. Participants are
LITERATURE REVIEW 7
representative of the population being studied with all being currently unemployed new
registered nurse graduates. The study does not mention statistical power for appropriate sample
size. Completion rate of the survey is not mentioned in the study. Modified Casey-Fink Graduate
Nurse Experience Survey was administered and likely a valid and reliable tool. Statistical
significance was not measured and confidence intervals are not present. Person confounding is
possible since students from 23 different schools of nursing and various degree programs,
including associate, baccalaureate, and direct entry master degrees, are all included in the same
sample. The results are applicable to practice and can be used to consider confidence and
competence gaps of new graduate nurses.
Qualitative Studies
Yee-Shuri Law, & Chan (2015) is a level 7 (Polit & Beck, 2017) narrative inquiry study
based on three new graduate nurses in Hong Kong. The findings cannot be transferable to all new
graduate nurses, but meant to help others to understand the process of learning to speak up for
one’s self.
Ortiz (2016) is a level 7 (Polit & Beck, 2017) descriptive qualitative study with a
convenience sample of 12 new graduate nurses. Data was collected with the use of interviews.
Results are not transferable to all new graduate nurses related to the small purposive sample of
participants from two hospitals in the New York area. The results from the study give insight
about the process of developing professional confidence.
Literature Reviews
Shatto & Lutz (2017) is a level 8 (Polit & Beck, 2017) literature review that included
evidence from 12 primary source articles about transition to practice of new nurses from 2003-
2017. All of the research is focused on the nursing profession. The articles used are from
LITERATURE REVIEW 8
academic journals, but do not specifically state as peer-reviewed. Shatto & Lutz review is
summary of the existing work and does not identify gaps in literature or critically appraise the
articles. The review is organized, objective, and tentative in language with the use of
paraphrasing when discussing findings. The literature review does not make education or
practice implications. The review is not part of a research report and there is no clear support for
new research studies.
Foronda, MacWilliams, & McAuthur, 2016 is a level 8 (Polit & Beck, 2017) literature
review that included primary source evidence from 18 research studies, six papers, three
literature reviews, and one theoretical framework paper from 2005 until 2014. The literature
review includes research from various disciplines which is appropriate since focusing on
interprofessional communication. The literature review does not include peer-reviewed as an
inclusion criteria. The research is well-organized, appraised and compared within the literature
review. The review does have many quotes embedded from the original evidence, but does
examine the limitations. The review discusses recommendations for both education and practice.
Areas for further exploration is discussed.
Synthesis
Based on the evidence for this literature review, three synthesis statements can be made.
First, new graduate nurses have a lack of confidence (Ortiz, 2016); (Yee-Shuri Law, & Chan,
2015); (Berman et al., 2014). Second, new graduate nurses have a difficult time speaking to
physicians (Berman et al., 2014); (Shatto & Lutz, 2017); (Foronda, MacWilliams, & McAuthur,
2016); (Ortiz, 2016); (Yee-Shuri Law, & Chan, 2015). Third, simulation experiences have a
positive influence on confidence of new graduate nurses (Foronda, MacWilliams, & McAuthur,
2016); (Salam, Saylor, & Cowperthwait, 2014); (Rhodes et al., 2016).
LITERATURE REVIEW 9
Conclusion
There is a lack of evidence about the author’s PICOT question. The article by Salam,
Saylor, & Cowperthwait (2014) was the closet fit to the PICOT question, but does not discuss
confidence of new graduate nurses. Confidence of new graduate nurses about raising concerns
about patient changes to physicians needs to be studied. The nurse-physician relationship is vital
for safe patient outcomes and should be research in order to find ways to improve the transition
from education to practice for nurses. Simulation is a useful teaching method in education and
practice. Evidence searches reveal less available research about the use of simulation in practice.
More research about the use of simulation in practice is needed. Focus on these simulations
effect on working with the interprofessional team and effect on confidence of new nurses should
be explored.
This paper explored the relevant literature about new nurse confidence levels
communicating with physicians. Creative searching was needed to expand the topic to find
research to review. The lack of evidence was not anticipated by the author of the paper. The
analysis of literature found limited strength of evidence. Generalizability and transference from
the research to a greater audience is limited. There is an obvious gap in the research for the
author’s PICOT question. More research needs to be done to explore ways to increase confidence
of new graduate nurses discussing patient concerns to physicians. This topic is important to
explore and an appropriate focus for a Doctor of Nursing scholarly project.
LITERATURE REVIEW 10
References
Berman, A., Beazley, B., Karshmer, J., Prion, S., Van, P., Wallance, J., & West, N. (2014).
Competence gaps among unemployed new nursing graduates entering a community-
based transition-to-practice program. Nurse Educator, 39(2), 56-61. doi:
10.1097/NNE.0000000000000018.
Center for Evidence-Based Management (2018). Critical Appraisal of a Cross-Sectional Study
(Survey). [online]. Retrieved from https://www.cebma.org/wp-content/uploads/Critical-
Appraisal-Questions-for-a-Cross-Sectional-Study-july-2014.pdf.
Critical Appraisal Skills Programme (2018). CASP Cohort Study Checklist. [online]. Retrieved
from https://casp-uk.net/wp-content/uploads/2018/01/CASP-Cohort-Study-Checklist.pdf.
Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in
healthcare: An integrative review. Nurse Education in Practice, 1936-40. doi:
10.1016/j.nepr.2016.04.005
Law, B.Y., & Chan, E.A. (2015). The experiences of learning to speak up: a narrative inquiry on
newly graduated registered nurses. Journal of Clinical Nursing, 24(13/14), 1837-1848.
doi: 10.1111/jocn.12805
National Council of State Boards of Nursing (NCSBN) (2016). 2016 NCLEX-RN Test Plan.
Retrieved from https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf
Ortiz, J. (2015). New graduate nurses’ experiences about lack of professional confidence.
Journal of Continuing Education in Nursing, 46(1), 34-40. doi:10.3928/00220124-
20141122-01.
Polit, D. & Beck, C. (2017). Nursing Research Generating and Assessing Evidence for Nursing
Practice. (10th ed.). Philadelphia: Wolters Kluwer.
LITERATURE REVIEW 11
Rhodes, C.A., Grimm, D., Kerber, K., Bradas, C., Halliday, B., McClendon, S., & Medes, J.,
Noeller, T.P., & McNett, M. (2016). Evaluation of nurse-specific and multidisciplinary
simulation for nurse residency programs. Clinical Simulation in Nursing, 12(7), 243-250.
doi:10.1016/j.ecns.2016.02.010
Salam, T., Saylor, J.L., & Cowperthwait, A.L. (2015). Attitudes of nurses and physicians trainees
toward an interprofessional simulated education experience on pain assessment and
management. Journal of Interprofessional Care, 29(3), 276-278. doi:
10.3109/13561820.2014.950726
Shatto, B., & Lutz, L.M. (2017). Transition from education to practice for new nursing
graduates: A literature review. Creative Nursing, 23(4), 248-254. doi: 10.1891/1078-
4535.23.4.248.
Running head: HOMELESS VA CARE 1
Homeless Veteran Care Coordination Literature Review
Student Name
Northern Kentucky University
Running Head: HOMELESS VA CARE 2
Homeless Veteran Care Coordination Literature Review
Introduction
There are 21 million veterans in the United States with about 25% of them using VA
healthcare services (Haibach et al., 2017; Weber, Lee, & Martsolf, 2017). In 2009, Veterans
made up sixteen percent of the homeless as compared to eight percent of the total population
(Perl, 2015). This glaring disparity gave rise to numerous initiatives over the past eleven years
designed to improve access to care and health outcomes (Perl, 2015). The major platform for
change was based on collaborative efforts between federal government agencies and local
community leadership all across the nation (Perl, 2015).
Despite progress in recent years, veterans continue to have a disproportion amount of
homelessness when compared to the general population (Fargo et al., 2012; Perl, 2015; Weber et
al., 2017). At this point in time, on any given night there are approximately 50,000 homeless
veterans (Perl, 2015; Weber et al., 2017). Current data shows veteran homelessness is down by
nearly fifty percent since 2010 (U.S. Department of Veterans Affairs, 2017). To further support
these statistics, three states and fifty-nine communities have declared an end to veteran
homelessness (U.S. Department of Veterans Affairs, 2017). Despite this success, veteran
homelessness continues to be overrepresented (U.S. Department of Veterans Affairs, 2017) with
limited research showing the impact of housing on health outcomes (Gabrielian, Yuan,
Andersen, Rubenstein, & Gelberg, 2014).
Practice Question and Population
Veterans are an ethnically diverse group of adult men and women over the age of
eighteen who have served in the armed services and meet eligibility criteria for services provided
by the Department of Veteran Affairs (VA) (Perl, 2015). The wide spread homeless veteran
Running Head: HOMELESS VA CARE 3
outreach programs Department of Housing and Urban Development and Veterans Affairs
Supportive Housing (HUD-VASH) have successfully enrolled thousands of homeless veterans
defined as a lack of nighttime routine housing that does not include shelters or requires frequent
moves (Perl, 2015).
When reviewing the literature related to the question, several gaps are noted in
interdisciplinary collaboration and patient outcome metrics that make one question the
possibility of aligning existing interdisciplinary resources in a manner that provides added
efficiency and clinical benefit. Much of the literature uses health care utilization patterns as a
proxy for health needs, but this does not necessarily approximate the amount of disease burden
and actual interventions with measured health outcomes remain relatively unexplored
(Gabrielian et al., 2014). This led to the development of the question: Does interdisciplinary care
coordination reduce the burden of disease in veterans enrolled in the HUD-VASH program with
two or more comorbid conditions six months after implementation?
Review of Literature
Study Identification Method
The key words established for the literature review included review using the NKU
library, Cumulative Index to Nursing and Allied Health Literature (CINHAL) and google scholar
in peer reviewed publications with full text available since 2009. This date was chosen due the
fact that the VA initiated a complete revision and expansion of the homeless programs during
this period (U.S. Department of Veterans Affairs, 2017). For example, the term homeless and
Veteran in the NKU library search engine returned 16,326 entries.
When the key words nursing was combined with the subjects of chronic disease (56) and
care transition (1), and case management (51) a total of 108 studies were identified. When the
Running Head: HOMELESS VA CARE 4
key words social work was combined with the subjects of chronic disease (87) and care
transition (2), and case management (146) a total of 235 studies were identified. The abstracts
were then reviewed, and the literature selected was based on the criteria of using a VA based
health care system homeless population with descriptive data, interventions, or veteran health
outcomes. This narrowed the studies down to a total of fifteen articles that were included in this
literature review.
Review
Tsai and Rosenheck (2015) completed a meta-analysis to summarize risk factors for
homelessness among service members. Their review of thirty-one studies found a lack of
rigorously designed studies, no prospective cohort or experimental studies, a lack of sufficient
retrospective cohort studies and case-control studies (Tsai & Rosenheck, 2015). Weber, Lee and
Martsolf (2017) also conducted a meta-analysis to educate nurses on the challenges faced by
veteran patients. This analysis was consistent with the one conducted by Tsai and Rosenheck
(2015) and mainly produced descriptive type data (Weber et al., 2017).
Axon et al. (2016) reported to be the only study that linked uncontrolled diabetes in all
ethnic groups of homeless populations when compared to the control. Although these findings
seem obvious as they logically relate to limited resources that include a lack of quality food, the
uncontrolled diabetic state continued after the provision of permanent housing (Axon et al.,
2016). The authors suggested that additional studies should be conducted that potentially could
expand the knowledge base on chronic medical conditions that impact the homeless after they
receive housing to explain this finding (Axon et al., 2016).
Interventions designed to modify primary care models in order to create a “one stop”
experience that measured health care utilization outcomes reported limited success (Gundlapalli
Running Head: HOMELESS VA CARE 5
et al., 2017; O’Toole, Johnson, Aiello, Kane, & Pape, 2016). In both studies, the lack of
appropriate discipline representation was acknowledged when social workers were added to the
expanded Homeless Patient Aligned Care Team (HPACT) teams to address rapid housing,
access to food, behavioral health and creating links with other community agencies (O’Toole et
al., 2016).
However, maintaining this model is expensive as it limits efficiency due to limited patient
panels and inability to predict consistent demand (Gundlapalli et al., 2017; O’Toole et al., 2016).
The HPACT model also requires additional management resources as patients have to be
transitioned across continuums of care as they stabilize or debilitate (O’Toole et al., 2016). In
both studies, there were favorable reports of utilization trends, but the periods were brief and
lacked strong statistical analysis.
Gabrielian et al. (2013) initiated a study that placed home telehealth equipment in the
homes of newly housed veterans with chronic disease. The intervention focused on the
applicability of the equipment and recently homeless patients acceptance of the equipment
(Gabrielian et al., 2013). They initiated a peer support mechanism to aid in the adoption of the
technology, but found that the majority of patients did not find it valuable (Gabrielian et al.,
2013). While the report suggests that the intervention is feasible and encourages the use of such
tools, it stops short of reporting any changes in patient outcomes related to chronic disease
(Gabrielian et al., 2013).
Appraisal and Synthesis
The literature related to care coordination in the homeless population is limited and
inconsistent. Difficulty in scheduling, transportation, job placement, child care, personal
belongings security and ethical boundaries pose major barriers when working with this
Running Head: HOMELESS VA CARE 6
vulnerable population (Haibach et al., 2017; Tsai & Rosenheck, 2015). Additionally, most
studies relied on self-report, lacked rigorous methods, comprehensive measurement tools and
risk factor identification that could be influenced by intervention (Tsai & Rosenheck, 2015). An
example of the inconsistency is demonstrated by Gabrielian et al. (2014) who reviewed health
care utilization patterns with a social work case management HUD-VASH program and found an
increase in health care consumption post housing placement. A study conducted by Montgomery
et al. (2013), had an opposing finding in that housing for veterans was associated with the
reduction of health care utilization.
There is agreement across the body of evidence where veterans report more mental health
conditions, chronic diseases, comorbidities and social isolation than non-veteran populations
(Byrne, Montgomery, & Fargo, 2016; Montgomery, Byrne, Treglia, & Culhane, 2016;
Montgomery, Hill, Kane, & Culhane, 2013; Weber et al., 2017). Utilization patterns of health
care services tends to be relatively similar across genders with the exception being that males use
more Emergency Department (ED) services and substance abuse treatment (Montgomery &
Byrne, 2014). In general, individuals enter the military with a higher state of health than the
general population due to military selection and screening processes (Byrne et al., 2016; Perl,
2015).
However, upon discharge from the military the opposite is true. Individuals who
transition from the military have higher rates of Post-Traumatic Stress Disorder (PTSD), tobacco
use, alcohol and substance use disorder, suicide and chronic disease (Byrne et al., 2016; Perl,
2015). This is a real challenge due to the fact that the population has access to a full complement
of social work services, clinical health care in both inpatient and outpatient settings at
community VA clinics and hospitals (U.S. Department of Veterans Affairs, 2017).
Running Head: HOMELESS VA CARE 7
Conclusion
After reviewing the literature, there is an absence of information related to evidence-
based interventions pertaining to care coordination and health outcomes of homeless veterans
enrolled in the HUD-VASH program. The VA and partnership communities have accomplished
a great deal in relation to housing homeless veterans. However, there is an obvious lack of
interventions and guidance needed to address the chronic disease demands of veterans in the
HUD-VASH program (Gabrielian et al., 2013). As Tsai & Rosenheck (2015) found, there is
very limited level I evidence in this review (Table 1). The two meta-analyses were focused on
characteristics and systems which are lacking strong interventions and outcomes.
The literature related to care coordination tends to be focused on a singular discipline like
social work and focused on outcomes that align with programmatic objectives. Additional
research is necessary that goes beyond creating a “one stop” shop with the expectation of a
decrease in utilization trends. Interventions that focus on the roles of the interdisciplinary team
with patient outcome metrics would add tremendously to this body of literature.
The limited knowledge base of proven interventions that effectively address the medical,
behavioral, and resource needs of the homeless pose and incredible challenge for nurses working
to improve clinical outcomes. The limited body of literature requires that nurses take the lead
and develop the tools and skills necessary to appropriately care for this population. Nurses can
contribute to the solution of these concerns by developing comprehensive discharge planning,
screening tools, and processes that ensure the timely delivery of care designed around the needs
of the homeless veteran (Weber et al., 2017).
This population needs the view point of nurses as the whole person must be
conceptualized in a manner that eliminates disparities. To accomplish this task, nurses must
Running Head: HOMELESS VA CARE 8
learn to be strong advocates and knowledgeable interdisciplinary team members with knowledge
of appropriate resources. The nursing profession is perfectly suited for this task and have the
potential to influence the health care team to move beyond these current gaps in knowledge
(Weber et al., 2017).
Conceptually, the collaborative reinvention of the roles of the social worker and nurse
into an integrated case management team is not a new undertaking. I am planning on creating
this type of collaboration as part of my DNP project. Unfortunately, previous studies missed an
opportunity to fully leverage the role of the nurse. The VA system provides an environment that
is uniquely positioned to study the relationship between homeless health care utilization,
outcome measures and the impact of an interdisciplinary care coordination model. Haibach et al.
(2017) states that our role in health care is to address challenges like this one so that we can
influence the health of systems. If done correctly, these changes take place as part of a rapid
quality improvement process that results in lifelong impacts for patients and communities
(Haibach et al., 2017).
.
Running Head: HOMELESS VA CARE 9
References
Axon, R. N., Gebregziabher, M., Dismuke, C. E., Hunt, K. J., Yeager, D., Ana, E. J. S., & Egede,
L. E. (2016). Differential Impact of Homelessness on Glycemic Control in Veterans with
Type 2 Diabetes Mellitus. Journal of General Internal Medicine, 31(11), 1331–1337.
https://doi.org/10.1007/s11606-016-3786-z
Byrne, T., Montgomery, A. E., & Fargo, J. D. (2016). Unsheltered Homelessness Among
Veterans: Correlates and Profiles. Community Mental Health Journal, 52(2), 148–157.
https://doi.org/10.1007/s10597-015-9922-0
Fargo, J., Metraux, S., Byrne, T., Munley, E., Montgomery, A. E., Jones, H., … Culhane, D.
(2012). Prevalence and Risk of Homelessness Among US Veterans. Preventing Chronic
Disease, 9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3337850/
Gabrielian, S., Yuan, A., Andersen, R. M., McGuire, J., Rubenstein, L., Sapir, N., & Gelberg, L.
(2013). Chronic disease management for recently homeless Veterans: a clinical practice
improvement program to apply home telehealth technology to a vulnerable population.
Medical Care, 51(3 0 1), S44–S51. https://doi.org/10.1097/MLR.0b013e31827808f6
Gabrielian, S., Yuan, A. H., Andersen, R. M., Rubenstein, L. V., & Gelberg, L. (2014). VA
Health Service Utilization for Homeless and Low-income Veterans. Medical Care, 52(5),
454–461. https://doi.org/10.1097/MLR.0000000000000112
Gundlapalli, A. V., Redd, A., Bolton, D., Vanneman, M. E., Carter, M. E., Johnson, E., …
O’Toole, T. P. (2017). Patient-aligned Care Team Engagement to Connect Veterans
Experiencing Homelessness With Appropriate Health Care. Medical Care, 55, S104.
https://doi.org/10.1097/MLR.0000000000000770
Running Head: HOMELESS VA CARE 10
Haibach, J., Haibach, M., Hall, K., Masheb, R., Little, M., Shepardson, R., … Goldstein, M.
(2017). Military and veteran health behavior research and practice: challenges and
opportunities. Journal of Behavioral Medicine, 40(1), 175–193.
https://doi.org/10.1007/s10865-016-9794-y
Montgomery, A. E., & Byrne, T. H. (2014). Services Utilization Among Recently Homeless
Veterans: A Gender-Based Comparison. Military Medicine, 179(3), 236–239.
https://doi.org/10.7205/MILMED-D-13-00426
Montgomery, A. E., Byrne, T. H., Treglia, D., & Culhane, D. P. (2016). Characteristics and
Likelihood of Ongoing Homelessness Among Unsheltered Veterans. Journal of Health
Care for the Poor and Underserved, 27(2), 911–922.
https://doi.org/10.1353/hpu.2016.0099
Montgomery, A. E., Hill, L. L., Kane, V., & Culhane, D. P. (2013). Housing Chronically
Homeless Veterans: Evaluating the Efficacy of a Housing First Approach to Hud-Vash.
Journal of Community Psychology, 41(4), 505–514. https://doi.org/10.1002/jcop.21554
O’Toole, T. P., Johnson, E. E., Aiello, R., Kane, V., & Pape, L. (2016). Tailoring Care to
Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans
Health Administration’s “Homeless Patient Aligned Care Team” Program. Preventing
Chronic Disease, 13, E44. https://doi.org/10.5888/pcd13.150567
Perl, L. (2015). Veterans and Homelessness (CRS Report RL34024). Washington, DC:
Congressional Research Service. Retrieved from
https://digitalcommons.ilr.cornell.edu/key_workplace/1481
Tsai, J., & Rosenheck, R. A. (2015). Risk Factors for Homelessness Among US Veterans.
Epidemiologic Reviews, 37(1), 177–195. https://doi.org/10.1093/epirev/mxu004
Running Head: HOMELESS VA CARE 11
U.S. Department of Veterans Affairs. (2017, May 3). U.S. Department of Housing and Urban
Development-VA Supportive Housing (HUD-VASH) Program [General Information].
Retrieved April 22, 2018, from https://www.va.gov/homeless/hud-vash.asp
Weber, J., Lee, R., & Martsolf, D. (2017). Understanding the health of veterans who are
homeless: A review of the literature. Public Health Nursing, 34, 505–511. Retrieved from
https://onlinelibrary.wiley.com/doi/full/10.1111/phn.12338
Table 1
Literature Evaluation
Citation Type of
Evidence
Level Strength
Axon, 2016. Differential Impact of Homelessness on Glycemic
Control in Veterans with Type 2 Diabetes Mellitus.
Cohort IV Moderate
Byrne, 2016. Unsheltered Homelessness Among Veterans:
Correlates and Profiles
Cohort IV Moderate
Fargo, 2012. Prevalence and Risk of Homelessness Among US
Veterans.
Cohort IV Moderate
Gabrielian, 2013. Chronic disease management for recently
homeless Veterans: a clinical practice improvement
Cohort IV Moderate
Gabrielian, 2014. VA Health Service Utilization for Homeless and
Low-income Veterans
Cohort IV Moderate
Gundlapalli, 2017. Patient-aligned Care Team Engagement to
Connect Veterans Experiencing Homelessness With Appropriate
Health Care.
Cohort IV Moderate
Haibach, 2017. Military and veteran health behavior research and
practice: challenges and opportunities
Cohort IV Moderate
Montgomery, 2014. Services Utilization Among Recently
Homeless Veterans: A Gender-Based Comparison.
Cohort IV Moderate
Montgomery, 2016. Characteristics and Likelihood of Ongoing
Homelessness Among Unsheltered Veterans.
Cohort IV Moderate
Running Head: HOMELESS VA CARE 12
Montgomery, 2013. Housing Chronically Homeless Veterans:
Evaluating the Efficacy of a Housing First Approach to Hud-Vash.
Cohort IV Moderate
O’Toole, 2016. Tailoring Care to Vulnerable Populations by
Incorporating Social Determinants of Health: the Veterans Health
Administration’s “Homeless Patient Aligned Care Team”
Cohort IV Moderate
Perl, 2015. Veterans and Homelessness (CRS Report RL34024) Systematic
Review
I High
Tsai, 2015. Risk Factors for Homelessness Among US Veterans Systematic
Review
I High
U.S. Department of Veterans Affairs. 2017. HUD-VASH Program Policy
Weber, 2017. Understanding the health of veterans who are
homeless: A review of the literature.
Systematic
Review
I High
NKU- DNP Theory and Research
MODULE 6
Module 6: Assignment — Construction of Clinical/Practice Question and Literature
Prompt:
The purpose of this assignment is to state your clinical/practice question and explore the literature pertaining to your clinical/practice problem as you described in your Module 3 Discussion Board . According to Moran et al. (2020) when conducting a literature review, the goal is to obtain a representative sample of the literature which describes the concepts related to the phenomenon of interest and the research results applicable to the clinical/practice question and identify what gaps need to be further researched. Your work for this paper may be used to build upon your scholarly project and publishable manuscript—thus it is important that you align your literature review with the topic you have selected (or are considering) for your PICOT question and DNP project.
This assignment is due Sunday, Week 6, by 11:59 PM EST. This assignment is worth 25% of Course Grade.
Instructions:
1. Please follow the rubric below.
2. Your work for this paper may be used to build upon your scholarly project and publishable manuscript—thus it is important that you align your literature review with the topic you have selected (or are considering) for your PICOT question and DNP project.
3. Paper length is no more than 8 pages
excluding
references and title page.
Exemplars—-I am providing 2 exemplars for you to view. Neither of these papers are perfect, nor did either paper earn 100%. However, each paper is excellent. These exemplars are shared just for you to ‘see’ what your paper might ‘look’ like. Please note that you must write your paper according to APA…this is a format as well as a method for citing and referencing. In the grading rubric, please also see that 30 points are allotted to the writing of a graduate level paper. If you are having difficulty with your writing, you may want to make an appointment with the NKU Writing Center for assistance.
CLIENT’S COMMENTS & REQUIREMENTS
Paper length is no more than 8 pages
excluding
references and title page
1. INTRODUCTION AND QUESTION a. Describe the clinical or practice problem you would like to address for your DNP project. State why this problem is an issue. Support your reasoning/rationale as to why this is an issue with current data or literature. b. State the practice question you wish to address in PICOT format (this should be the response to the problem defined above).-DOES THE USE OF AN AI-BASED NURSING APPLICATION SYSTEM IMPROVE NURSE’S ABILITY TO PROVIDE CARE TO PATIENTS WITHIN 6 MONTHS? why it is an issue may be because without nursing based application, there has been errors in medication compliance and adherence,
Does the use of an AI-based nursing application system improve nurses’ ability to provide care to patients?
P: Nurses
I: Use of an AI-based nursing application system
C: No intervention
O: Improved ability to provide care to patients
T: 6 months
2. State the population and setting being addressed- am thinking nurses that see patients in a home environment or home health
3. Introduction to the Literature Review on the topic
SECTION II REVIEW OF LITERATURE Includes most of the major studies conducted on the topic, including but not limited to, recent literature (last 5-7 years)—-a minimum of 10 articles is required
Includes primarily research studies, systematic reviews and guidelines addressing the practice question you wish to address.
Similar and discrepant research findings discussed.
SECTION 3-APPRAISAL AND SYNTHESIS Critically appraises the contributions of key studies and provides the strengths of evidence.
Describes the weaknesses in existing studies and identifies important gaps in the literature.
Conceptually organized based on type of articles and findings.
Succinctly summarizes and synthesizes findings
SECTION 4- FURTHER RESEARCH Identifies what ideas need to be further researched.
Then there is another rubric under these listed above to show content etc, RUBRIC RUBRIC RUBRIC is all they go by also and this assignment has 25 percent of major grade and am attaching one peer suggestion of this article from previous responses in class maybe it will help
Your topic has so much potential! We’ve only begun to unlock the possibilities that technology has to offer healthcare. I could see AI being applied to nursing care plans, for example. An article by Ronquillo and others (2021) discusses this and many other topics and helps to identify some of the gaps where AI might be part of the answer. I cited it for another class and I believe it may be of use to you as you explore your topic.
References
Ronquillo, C. E., Peltonen, L., Pruinelli, L., Chu, C. H., Bakken, S., Beduschi, A., Cato, K., Hardiker, N., Junger, A., Michalowski, Nyrup, R., Rahimi, S., Reed, D. N., Salakoski, Salantera, S., Walton, N, Weber, P., Wiegand, T., & Topaz, M. (2021). Artificial intelligence in nursing: Priorities and opportunities from an international invitational think-tank of the Nursing and Artificial Intelligence Leadership Collaborative.
Journal of Advanced Nursing, 77(9), 3707-3717.
Https://doi.org/10.1111/jan.14855 (Links to an external site.)
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