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
major studies conducted on the topic, including recent literature (last 5-7 years)—-a minimum of 10 articles is required.

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;
readability of paper only slightly affected by mistakes.

Some
problems with sentence structure, grammar, punctuation, and/or spelling; may have several run-on sentences or comma splices; some errors in citation style; format does not fully comply with assignment guidelines; somewhat difficult to read due to mistakes.

Many difficulties in sentence structure, grammar, citation style, punctuation, spelling and/or misused words; proper format not used consistently
; many errors in citation style very difficult to understand.

Not written at a graduate level; many mistakes; proper format not used consistently
; many errors in citation style; difficult to read and understand.

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.
*Plagiarized — 

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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