CAPSTONE PROJECT: RESOLUTION OF THE PROBLEM/CONCERN (Latest Update) Already Graded A+

Rebecca Murphy Chamberlain College of Nursing NR660: Capstone Project: Resolution of the problem/concern DATE Capstone Project: Resolution of the problem/concern The purpose of this assignment is to analyze the proposed capstone project and the measurable outcomes of implementing the chosen project. The assignment shall contain five sections. These sections include discussion of the evidence-based solution, the selected change theory model that will be used for the project, evaluation of the project to include objectives, utilizing new modalities or methods of sharing scholarship and lastly, applying knowledge gained from previous courses. Evidence-based solution Before discussing the evidence-based solution to the problem, the PICOt problem must first be identified. P - Patients discharged after being treated for a stroke. I - Discharge planning and education regarding medication/lifestyle modification adherence. C – No discharge planning or education. O – Reduce readmission rates from 6/month to 3/month. T – 3 months post initial stroke. Stroke has fallen from the third leading cause of death to the fifth, yet it remains to be the number one cause of disability in America (CDC.gov, 2017). Why is it so common that patients return to the hospital, often less than 30 days, with recurring symptoms related to their ischemic stroke? The answer is related to knowledge deficit regarding their disease process. Not only are the patients lacking knowledge of their specific illness, but they are overall lacking health related knowledge all together. Bickel, Moody, and Higgins (2016) write that, to be effective as providers, we must promote a change in health-related behavior. Health-related behavior can be described as lifestyle modification, medication adherence and active promotion to change the view and culture of preventative medicine in the eyes of the patient (Bickel, Moody & Higgins, 2016). A simple solution to the problem may be increasing education and discharge teaching to daily instead of at the end of the hospitalization. So why is it so important that patients be active participants in their own readmission prevention program? Currently, the cost of stroke in the United States averages 34 billion annually (CDC.gov, 2017). Most patients who have strokes did not know exactly what to do to prevent the first one from occurring, but they certainly can be educated on how to prevent subsequent strokes. Desired outcomes for the capstone project include establishing a discharge education process that educates the patients daily; covering several aspects such as lifestyle modification, medication adherence, importance of follow up and what to expect after discharge. From a financial stand point, a reduction in readmission related to stroke would be expected, as well as reimbursement revenue from the Centers for Medicare and Medicaid Services (CMS). By utilizing existing bedside staff, the capstone project also does not affect the organizations budget. Identification and inclusion of a change theory Several applicable change models can be applied to this project, however, I found two that fit perfectly. One applicable nursing theory would be Dorothy Orem’s Self Care Deficit. This theory is commonly used by nurses to guide and improve best practice. Orem’s theory contains three related parts. These parts consist of the theory of self-care, self-care deficit and the nursing system (TK & Chandran, 2017). This theory is useful for the PICO(t) question as it describes the theory’s assumptions pertaining to people as being self-reliant and responsible for their own care, that people are distinct individuals, that nursing is an action and involves interaction between two or more people (TK & Chandran,2017). Orem’s theory also states that a person’s knowledge of health problems is needed for promoting self-care behavior and that self-care and dependent care behaviors are learned within a socio-cultural environment. This theory fits well with the importance of discharge education and disease process teaching. The second change model that I chose was Lewin’s change model. This theory consists of three major concepts or stages; unfreezing, change and refreezing. To describe further, refreezing can be stated as unlearning a process or habit, change involves replacing that habit with a new process and refreezing involves establishing the new habit so that it becomes the standard of care (TK & Chandran, 2017). Orem’s theory applies to the patient’s readiness to learn and the nurses’ ability to deliver to content. Lewin’s change model refers more to the bedside nurse’s ability to adapt to the process change and apply the new process daily. Comprehensive and measurable plan The first measurement of value would be analyzing readmission rates pre-project application and readmission rates post project application after a predetermined time frame. The PICOt poses an evaluation of success at 3 months. To be more specific, measuring the number of patients returning to the hospital after their initial stroke at three months. The obvious goal is to greatly reduce the number of patients returning to the hospital as a result of increased knowledge and education regarding their stroke diagnosis. Another technique to measure patient knowledge is to incorporate the teach back method. Evidence-based research supports the use of the teach back method as a means of successfully educating patients with chronic disease states in an effort to maximize their understanding, knowledge and promote self-care skills (Dinh, Bonner, Clark, Ramsbotham, & Hines, 2016). The nurse measures success when the patient can accurately repeat back the teaching he/she has learned. A SWOT analysis was performed to examine strengths and weaknesses of the proposed project. SWOT Analysis Discharge Stroke Education Helpful to achieving the objective Harmful to achieving the objective Internal origin (attributes of the system) Strengths • Reduces recurrence of secondary strokes. • Reduces readmission related to medication noncompliance and misunderstanding of related stroke complications. • Increases CMS reimbursement funds by lowering overall percentage of hospital readmissions. Weaknesses • Pts/families are in acute medical crisis and may not always absorb information being offered. • Pts may not have resources available to adhere to recommended lifestyle changes or ability to financially afford prescribed medication. • Bedside nursing staff, PT, OT and SLP may not be adequately trained to teach pt. effectively. External origin (attributes of the environment) Opportunities • Bedside nursing staff in cooperation with PT, SLP and OT have the opportunity to daily educate the patient regarding discharge teaching. • Hospital has technology to imbed discharge teaching video into pt.’s TV and play education every day at a set time. • Daily group education can be held in a classroom for multiple pt.’s to attend to receive discharge teaching. Threats • Staff may not always have time and/or availability to educate the pt. on a daily basis. • Pt. may not be receptive or refuse teaching. • Pt. may turn off education/teaching video or not watch TV at all. • Pt.’s may not be able to physically attend class room education, requires staff to take and return pt. to room. Requires staff to take time to teach discharge education to group on daily basis. Preventing readmission is of course important for the well-being of the patients with in our community, but the organization stands to gain revenue from CMS reimbursements. A portion of this revenue would be beneficial in supporting continuing education for the bedside staff. Staff attendance at related topic seminars and conferences would serve to benefit the community as well as the organization. Giving back to the bedside staff would likely lead to nurse retention, saving the organization even more profit. New modalities of scholarship One way to reduce readmissions would be going “mobile”. As a leadership executive, we can’t just go to our patients houses and assess how well the discharge education or teaching was. But there are programs that exist for nurse practitioners (NP) and community paramedics (CP) to do just that. One such program exists in Manatee county, Florida (). The NP and CP follow up on low income/insured patients discharged with core measures illnesses. Knowledge deficit and health disparity has been documented as being higher among low income and the uninsured. This program allows the NP and CP to intervene on issues prior to the need for readmission. Another way to prevent readmission and disseminate knowledge is by incorporating a Transitional Care Clinic (TCC). The TCC is not without additional cost, however, the TCC can be managed by an NP who evaluates patients as they return to the emergency department (ED) for core measure related complaints. In order to qualify for the TCC, the patient must have been admitted for a core measure complaint within the last ninety days. The patient is not admitted until the NP determines if the patient can be managed at home or not. This strategy has prevented many readmissions. Additional methods to increase patient knowledge and education is to tailor it towards their learning preference. The younger patients would likely be open to technology such as learning videos or computer-based problem-solving exercises. What if the patient could participate in a game via the in-room TV. The game would teach the patient about stroke by “testing” their knowledge. They beat the game when they answer all the questions correctly. This would be ideal for transient ischemic attack (TIA) patients who are symptom free but are still at risk for stroke. The older population generally prefer face to face interaction with written follow up. This is where the bedside, teach back method becomes so important. Parappilly, Mortenson, Field and Eng (2019) discovered, that stroke survivors listed two main suggestions to preventing secondary stroke. The first was making sure to include the entire family unit in the teaching and second was to follow up approximately 2 weeks after the initial stroke for education reinforcement (Parappilly, Mortenson, Field & Eng 2019). Integration of knowledge from core and specialty track MSN program courses Synthesis of knowledge from graduate level nursing courses is essential for successful leadership skills. Classes such as healthcare policy, community education and leadership assisted in shaping the leadership style I have today. Additional to leadership classes, finance and epidemiology were vital in understanding the importance of organizational budgets and communicable diseases that affect our communities. I discovered that I lean towards the transformational style of leadership. I value the input of those around me and believe in empowering our nurses to make differences. Empowerment allows nurses to take ownership of ideas, projects or training which aids in satisfaction and retention. Additional to leadership style, I shifted my focus from individual to departmental to that of organizational. We historically tend to spend many years isolated in within our individual departments, sometimes, it is difficult to step outside those boundaries and think of leadership strategies that encompass an entire organization. When I obtained my bachelor’s degree, I advanced from the associate’s level of task orientation, to that of evidenced based practice, applying research and statistical analysis to my everyday nursing. I also discovered nursing theory and how it plays an important role in patient learning and safety. Now at the end of the master’s level, I feel I am prepared to incorporate the combined sum of knowledge from these courses. Experiences such as writing an executive summary, formulating a business plan, shadowing a mentor and the chief nursing officer (CNO) have all been invaluable towards my career advancement. As I attend collaborative meetings with peers and colleagues, I appreciate the level of understanding I now have regarding such topics as value-based purchasing, CMS and Medicare reimbursement, and the importance of staying under budget. Conclusion In conclusion, several topics were discussed in detail. Evidenced based solution explained the capstone project using a PICOt question. Focus was emphasized on why prevention of stroke readmission is necessary and the impact it has on the community and the organization. Two changes theories were summarized and how they each play a role in discharge education and teaching of the patient. Evaluation of the project discussed outcomes and how the project be measured in terms of success? Reduction in readmissions is perhaps the most measurable outcome to gauge whether the daily discharge education is successful. Statistical data and analysis allow for percentages of readmissions that can be disseminated and delivered to administration in an easy to follow graph. New modalities of scholarship included thinking outside the box to achieve success in the project goals. Several different methods of patient education are available and can easily be applied to the stroke patient. Lastly, synthesis of knowledge acquired during the master’s level courses was evaluated and discussed with insight measured as it pertains to career enhancement. Without a doubt, the courses were impactful and will benefit my future in executive leadership. References Bickel, W. K., Moody, L., & Higgins, S. T. (2016). Some current dimensions of the behavioral economics of health-related behavior change. Preventive Medicine, 92, 16-23. doi:10.1016/.2016.06.002 Dinh, H. T., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. The JBI Database of Systematic Reviews and Implementation Reports, 14(1), 210. doi:10.11124/jbisrir- Manatee county health care plan for low-income uninsured adults. (2016). Retrieved from Parappilly, B. P., Mortenson, W. B., Field, T. S., & Eng, J. J. (2019). Exploring perceptions of stroke survivors and caregivers about secondary prevention: a longitudinal qualitative study. Disability and Rehabilitation, 1-7. doi:10.1080/.2018. Stroke Facts. (2019, March 15). Retrieved from TK, A., & Chandran, S. (2017). Chapter-09 Dorothea Orem: self-care deficit theory. Application of Nursing Theories, 95-101. doi:10.5005/jp/books/13072_10