Question:
Develop an intervention (your capstone project), as a solution to the patient, family, or population problem you've
defined. Submit the proposed intervention to the faculty for review and approval. This solution needs to be
implemented (shared) with your patient, family, or group. You are not to share your intervention with your patient,
family, or group or move on to Assessment 5 before your faculty reviews/approves the solution you submit in
Assessment 4. In a separate written deliverable, write a 5– 7 page analysis of your intervention.
Please submit both your solution/intervention and the 5–7 page analysis to complete Assessment 4.
Introduction
In your first three assessments, you applied new knowledge and insight gleaned from the literature, from
organizational data, and from direct consultation with the patient, family, or group (and perhaps with subject matter
and industry experts) to your assessment of the problem. You’ve examined the problem from the perspectives of
leadership, collaboration, communication, change management, policy, quality of care, patient safety, costs to the
system and individual, technology, care coordination, and community resources. Now it’s time to turn your attention
to proposing an intervention (your capstone project), as a solution to the problem.
Preparation
In this assessment, you’ll develop an intervention as a solution to the health problem you’ve defined. To prepare for
the assessment, think about an appropriate intervention, based on your work in the preceding assessments, that will
produce tangible, measurable results for the patient, family, or group. In addition, you might consider using a root
cause analysis to explore the underlying reasons for a problem and as the basis for developing and implementing an
action plan to address the problem. Some appropriate interventions include the following:
Creating an educational brochure.
Producing an educational voice-over PowerPoint presentation or video focusing on your topic.
Creating a teaching plan for your patient, family, or group.
Recommending work process or workflow changes addressing your topic.
Plan to spend at least 3 direct practicum hours working with the same patient, family, or group.
In addition, you may wish to complete the following:
Review the assessment instructions and scoring guide to ensure that you understand the work you will be
asked to complete and how it will be assessed.
Conduct sufficient research of the scholarly and professional literature to inform your work and meet scholarly
expectations for supporting evidence.
Note: Remember that you can submit all, or a portion of, your draft assessment to Smarthinking for feedback,
before you submit the final version. If you plan on using this free service, be mindful of the turnaround time of 24–48
hours for receiving feedback.
Instructions
Complete this assessment in two parts: (a) develop an intervention as a solution to the problem and (b) submit your
proposed intervention, with a written analysis, to your faculty for review and approval.
Part 1
Develop an intervention, as a solution to the problem, based on your assessment and supported by data and
scholarly, evidence-based sources.
Incorporate relevant aspects of the following considerations that shaped your understanding of the problem:
Leadership.
Collaboration.
Communication.
Change management.
Policy.
Quality of care.
Patient safety.
Costs to the system and individual.
Technology.
Care coordination.
Community resources.
Part 2
Submit your proposed intervention to your faculty for review and approval.
In a separate written deliverable, write a 5–7 page analysis of your intervention.
Summarize the patient, family, or population problem.
Explain why you selected this problem as the focus of your project.
Explain why the problem is relevant to your professional practice and to the patient, family, or group.
In addition, address the requirements outlined below. These requirements correspond to the scoring guide criteria
for this assessment, so be sure to address each main point. Read the performance-level descriptions for each
criterion to see how your work will be assessed. In addition, note the additional requirements for document format
and length and for supporting evidence.
Define the role of leadership and change management in addressing the problem.
Explain how leadership and change management strategies influenced the development of your
proposed intervention.
Explain how nursing ethics informed the development of your proposed intervention.
Propose strategies for communicating and collaborating with the patient, family, or group to improve
outcomes associated with the problem.
Identify the patient, family, or group.
Discuss the benefits of gathering their input to improve care associated with the problem.
Identify best-practice strategies from the literature for effective communication and collaboration to
improve outcomes.
Explain how state board nursing practice standards and/or organizational or governmental policies guided
the development of your proposed intervention.
Cite the standards and/or policies that guided your work.
Describe research that has tested the effectiveness of these standards and/or policies in improving
outcomes for this problem.
Explain how your proposed intervention will improve the quality of care, enhance patient safety, and reduce
costs to the system and individual.Cite evidence from the literature that supports your conclusions.
Identify relevant and available sources of benchmark data on care quality, patient safety, and costs to
the system and individual.
Explain how technology, care coordination, and the utilization of community resources can be applied in
addressing the problem.
Cite evidence from the literature that supports your conclusions.
Write concisely and directly, using active voice.
Apply APA formatting to in-text citations and references.
Additional Requirements
Format: Format the written analysis of your intervention using APA style. Use the APA Style Paper Template.
An APA Style Paper Tutorial is also provided to help you in writing and formatting your paper. Be sure to
include:
A title page and reference page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
Length: Your paper should be approximately 5–7 pages in length, not including the reference page.
Supporting evidence: Cite at least five sources of scholarly or professional evidence that support your central
ideas. Resources should be no more than five years old. Provide in-text citations and references in APA
format.
Proofreading: Proofread your paper, before you submit it, to minimize errors that could distract readers and
make it more difficult for them to focus on its substance.
Portfolio Prompt: Save your intervention to your ePortfolio. After you complete your program, you may want to
consider leveraging your portfolio as part of a job search or other demonstration of your academic and professional
competencies.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies
through the following assessment scoring guide criteria:
Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
Define the role of leadership and change management in addressing a patient, family, or population
health problem.
Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care.
Explain how a proposed intervention to address a patient, family, or population health problem will
improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
Competency 4: Apply health information and patient care technology to improve patient and systems
outcomes.
Explain how technology, care coordination, and the utilization of community resources can be applied
in addressing a patient, family, or population health problem.
Competency 5: Analyze the impact of health policy on quality and cost of care.
Explain how state board nursing practice standards and/or organizational or governmental policies
guided the development of a proposed intervention.
Competency 6: Collaborate interprofessionally to improve patient and population outcomes.
Propose strategies for communicating and collaborating with a patient, family, or group to improve
outcomes associated with a patient, family, or population health problem.
Competency 8: Integrate professional standards and values into practice.
Write concisely and directly, using active voice.
Apply APA formatting to in-text citations and references.
Answer:
Patient, Family, or Population Health Problem Solution
Diabetes disease has affected the normal life of Jeremy, the patient described in this project, to a point where he no longer feels part of society anymore. He feels that he has become a burden to his family members as he depends on them for several needs. Diabetes is a focus of this project because it affects thousands of lives in America while the preventions and solutions lie within our reach. This problem is highly caused by lifestyle changes, and been aware of the right thing to do or eat can help manage the disease. The intervention proposed in this project is creating a teaching plan for the patient on their condition and how they should self-manage it.
The paper will also address the role of leadership and change management in addressing the problem, strategies for communicating and collaborating with the patient, and governmental policies that guided the development of the proposed intervention. It will also discuss how the proposed intervention will improve the quality of care, enhance patient safety, and reduce costs to the system and individual, and how technology, care coordination, and the utilization of community resources can be applied in addressing the problem.
Role of Leadership and Change Management
Leadership is an essential factor in driving the performance of nurses and other health care workers to improve the quality of care for diabetic patients. Transformational leaders ignite the engagement of nurses with their patients and rely on particular behaviors to allow better performance of tasks. The diabetic field is complex and fast-changing, and for great results, nurses must cope up. As leaders require team members who fully invest their energy into their roles, they also have to understand the factors that motivate their employees to produce outstanding outcomes (Lai et al., 2020, p. 1). Diabetic patients have different requirements, and no one solution fits all. Therefore, leaders should enhance work management and create more contact with their employees to encourage, guide, and motivate them on developing teaching plans for patients and helping the patients understand what is required of them in self-management. The specific leadership strategy that was used in developing the intervention is sustaining employee engagement in terms of change. This helped provide different ideas on how to improve diabetic information. Engaging employees helps them feel part of the intervention hence helping in the implementation.
The best change management strategies that will be utilized for this intervention include planning carefully, communicating, and inviting participation. For people to behave in a new way, they need to change from their old practices. Most of the existing value's come from the current organizational culture; that is how things are done. People being social have the nature to go along with what others are doing to fit in (Graamans et al., 2021). There is a need to develop a culture of continuous improvement that can help nurses to take upon a new intervention without any protests. When one understands the idea of continuous improvement, they are away that change is inevitable every now and then. This will help them take up the intervention and deal with patients on individual levels taking them through personalized educational health plans to manage their diabetes condition.
Nursing Ethics
Nursing ethics guide nurses to offer best practices when dealing with patients from all walks of life. The main principles of ethics include justice, non-maleficence, beneficence, and autonomy which did guide to come up with the intervention for this patient problem. In addition to these principles, there are provisions in the code of ethics that guide a nurse's actions. one provision states that the nurse's primary commitment is to the patient (Haddad & Geiger, 2020). In accordance with this, the patient is the main focus of the intervention. The patient has the right to choose the finest techniques in his care, and as a nurse, all you can do is educate them. In another provision, the nurse should consider the collaboration with other health professionals by guiding the patient to understand the importance of care coordination to realize a firm health plan.
Strategies for Communicating and Collaborating with the Patient
Effective communication is a great tool to improve nursing care. Communication skills enable nurses to understand the patient's needs clearly and understand the preferences and characteristics of their patient (Fakhr-Movahedi et al., 2016, p. 267). For Jeremy, a patient who has recently been diagnosed with diabetes needs a nurse that has good communication skills to understand his needs and communicate effectively about the health plan. Patients are quite inquisitive about their health conditions. Nurses should develop appropriate answers verbally by first analyzing patients' documents, observing health status, and asking questions. During active communication, nurses should show caring attention. This means that nurses should be accessible and gladly answer to requests made. They should clearly communicate about medications and other medical terms that the patient does not easily understand. Nurses should have the ability to induce calmness in the patient by listening to them attentively, practicing patience, and sympathizing with them (Fakhr-Movahedi et al., 2016, p. 270).
People cannot collaborate if they do not practice good communication methods. Collaboration is the increase in interactions to achieve a common goal. Nurses can collaborate with other healthcare professionals in providing the best practices to the patients. Additionally, collaboration involves coordination between the nurse and patient to achieve a common goal (Morley & Cashell, 2017, p. 208). This can be done by listening to the patients' preferences and correlating them with the best practices to achieve a shared goal. This requires shared decision-making as well as cooperation between the two. Diabetes management can only be achieved by utilizing these and other communication and collaborative strategies. The disease is highly influenced by actions people take every day, and therefore important for them to understand what affects them and how they can change their lives for the better.
Nursing Standards that Guided the Development of the Intervention
The ANA standards of professional performance guided the development of this intervention to help diabetes patients receive better care and manage the conditions better. These standards use the nursing process as a model to describe high levels of competent nursing care. The nursing process includes various components such as assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The first standard requires nurses to collect vital information about the patient's health and their situation. This is important as developing an education plan needs to understand the patient before a proper assessment. Diagnosis as the second standard allows a nurse to identify or confirm issues and problems faced by the patient. Through this standard, nurses can then identify expected outcomes through an individualized plan to the patient. Planning and implementation of working strategies can then be done and also identifying measurable outcomes. ANA standards also guide on other areas such as ethics, leadership, collaboration, communication, and culturally congruent practice (Indiana University, 2021).
The standards of nursing practice that the American Nurses Association provides apply to all nurses. This means that nurses utilize the standards in managing diseases such as diabetes. These standards are revised to ensure that they conform to changing times to promote patient care (Maloney, 2016, p. 327). Management of diabetes requires an informed strategy due to the increased complexity of the disease (Reusch & Manson, 2017). The ANA standards well guide this. This and other studies have clearly shown the importance of following the standards in the management of diabetes, which has been the basis of developing an intervention based on them.
Improving the Quality of Care, Enhancing Patient Safety, and Reducing Costs with the Intervention
This intervention helps improve care quality as it allows for personalized health education plans for the patient. Nurses will have the opportunity to interact more with the patient, identify what they need most, and build a rapport with them. Through interaction with other professionals, nurses can gain more knowledge on how to address the patient's problem. In diabetes management, errors in medication such as insulin could be fatal. Having an education plan that takes patients through procedures such as self-administration of insulin is important to improve the safety of the patient. Going through education plans also helps the nurses identify areas that require improvement to improve the patient's health. There are several ways through which costs to individuals and the system are incurred. Direct costs can be observed where the patient is constantly readmitted many times (Upadhyay et al., 2019). This can lead to high costs that are heavy for hospitals and individuals to manage. The intervention will help patients know how to manage their conditions better to avoid many visits back to the hospital.
External benchmarks aid in the tracking of quality enhancement in quality and safety measures. When comparing one's results to that of the best, benchmarking is essential. One may compare performance and judge areas that need improvement using data collected by organizations. Comparative data can be obtained in various ways, including the National Healthcare Disparities Report and the AHRQ's annual National Health Care Quality Report. This will help understand how to improve the plan for better outcomes. According to the literature, one of the best ways to improve patient safety is by speaking up (Nacioglu, 2016). This is consistent with this intervention as it helps common issues known by the community hence improving patient safety and outcomes. According to Wrathall & Belnap (2017), population health management is crucial to ensure low costs in healthcare. Where people are provided with better information on how to improve their health, hospital visits reduce as well as costs in maintain healthcare.
How Technology, Care Coordination, and Community Resources can help Address the Problem
Technology is important for diabetic patient to manage their conditions effectively. However, when patients are not well informed, they abandon the technology for other solutions, which may lower the quality of care. Through the education plan intervention, the patient will be informed on how to use insulin pumps in the right way without problems. Care coordination will also be emphasized in the education plan. This will help the patient understand the importance of liaising with a care coordinator to allow proper sharing of information, ensuring better health outcomes. Community resources near the patient will be identified, and the patient informed so as to access them at any time.
The technology that this intervention emphasizes is the insulin pump. This technology helps deliver insulin in a flexible way to the patient. It provides rapid-acting insulin to the body without much effort from the patient (Paldus et al., 2018). This technology has an in-built algorithm that effectively estimates the blood glucose levels hence providing better bolus doses. Patients can go on with their activities, such as driving and exercises, without any interference. By educating patients on how to use this technology in the intervention will make their life easier and minimize problems associated with its usage.
Conclusion
Patient health is vital for a nurse as this is what they are educated and trained for. To achieve quality health care, there is a need for good leadership and change management strategies to address diabetes. Communication with patients' needs to be open and constructive to identify their needs as well as discuss the right approach. The proposed intervention will help improve patient safety and care by incorporating technology, care coordination, community resources. With this, the patient's health should improve, and he can get back to his normal life.
References
Fakhr-Movahedi, A., Rahnavard, Z., Salsali, M., & Negarandeh, R. (2016). Exploring nurse's communicative role in nurse-patient relations: A qualitative study. Journal of Caring Sciences, 5(4), 267-276. https://doi.org/10.15171/jcs.2016.028
Graamans, E., ten Have, W., & Ten Have, S. (2021). Against the current: Cultural psychology and culture change management. Culture & Psychology, 27(2), 325-343. https://doi.org/10.1177/1354067x21993789
Haddad, L. M., & Geiger, R. A. (2020, September 1). Nursing ethical considerations - StatPearls - NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK526054/#:~:text=Nurses%20are%20advocates%20for%20patients,their%20own%20beliefs%20and%20values
Indiana University. (2021). ANA standards of professional performance. BSN Student Handbook. https://www.ius.edu/nursing/handbooks/bsn-handbook/standards-of-performance/ana-standards-of-professional-performance.html#:~:text=Standards%20of%20Practice%3A%20The%20Standards,planning%2C%20implementation%2C%20and%20evaluation
Lai, F., Tang, H., Lu, S., Lee, Y., & Lin, C. (2020). Transformational leadership and job performance: The mediating role of work engagement. SAGE Open, 10(1), 1-11. https://doi.org/10.1177/2158244019899085
Maloney, P. (2016). Nursing professional development. Journal for Nurses in Professional Development, 32(6), 327-330. https://doi.org/10.1097/nnd.0000000000000300
Morley, L., & Cashell, A. (2017). Collaboration in health care. Journal of Medical Imaging and Radiation Sciences, 48(2), 207-216. https://doi.org/10.1016/j.jmir.2017.02.071
Nacioglu, A. (2016). As a critical behavior to improve quality and patient safety in health care: Speaking up! Safety in Health, 2(1), 1-25. https://doi.org/10.1186/s40886-016-0021-x
Paldus, B., Lee, M. H., & O'Neal, D. N. (2018). Insulin pumps in general practice. Australian Prescriber, 41(6), 186-190. https://doi.org/10.18773/austprescr.2018.056
Reusch, J. E., & Manson, J. E. (2017). Management of type 2 diabetes in 2017. JAMA, 317(10), 1015-1016. https://doi.org/10.1001/jama.2017.0241
Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on hospital financial performance: A study of Washington hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 56, 1-10. https://doi.org/10.1177/0046958019860386
Wrathall, J. A., & Belnap, T. (2017). Reducing healthcare costs through patient targeting: Risk adjustment modeling to predict patients remaining high-cost. eGEMs (Generating Evidence & Methods to improve patient outcomes), 5(2), 1-10. https://doi.org/10.13063/2327-9214.1279100
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