Keep in mind that The Robots” are defined in the assignment as a

Keep in mind that “The Robots” are defined in the assignment
as “automated machines, actual robots, computer hardware,
software applications, etc.)”
The Humans (Episode 2)
For The Humans that were not replaced by The Robots, the
respite was short-lived. They soon discovered that there existed
another group of The Humans that had joined forces with The
Robots so as to destroy the profit margins of BoltonCorp. This
newly discovered group has been known by many names, but the
most ubiquitous name is customers. To the chagrin of The
Humans Known As Employees, The Humans Known As
Customers are just as necessary for the success of BoltonCorp,
and their demands must be met.
The Humans Known As Customers have two identifying
features that attempt to destroy the profit margins of any firm
that crosses their path. First of all, they want the price that they
must pay for the goods or services to be as close to zero as
possible. Second, they want the value that they receive from the
goods or services to be as high as possible. To put this in our
Value-Price-Cost (V-P-C) framework, they want to maximize
the V-P gap and minimize the P-C gap. Given that all of
BoltonCorp’s potential for profits is derived from the P-C gap,
efforts to minimize it are alarming, to say the least. (As if this
were not alarming enough, BoltonCorp has actually tasked some
of The Humans Known As Employees to make every effort to
attract MORE of The Humans Known As Customers! In an
unbelievable turn of events, BoltonCorp has actually i ncreased
its costs through marketing and advertising expenses to create
more interactions and engagements with those who want only to
reduce the price! Has BoltonCorp lost its mind? Does it even
know that maximizing the P-C gap is critical to survival?!)
Meanwhile, The Humans Known As Customers have created and
leveraged The Robots Who Reduce Information Asymmetry

(Web sites, apps, price comparison software, product reviews,
etc.) as their primary weapon against the profit margins of
BoltonCorp. Information asymmetry exists when the two parties
involved in a transaction have different amounts and types of
information. For example, BoltonCorp knows the exact cost to
deliver their goods or services, but the price that the The
Humans Known As Customers are willing to pay is unknown.
Conversely, The Humans Known As Customers know the exact
price that each of the goods or services is worth to them, but the
true costs are unknown. Both parties in each transaction desire
the other side to be as uninformed as possible. Put another way,
both sides are trying to maximize information asymmetry.
You are the CEO of BoltonCorp, a multinational firm that
operates in 27 countries. You are sure that you need The
Humans Known As Customers to be satisfied or else you will go
out of business. However, you prefer The Humans Known As
Customers to have zero information about your costs.
Unfortunately, The Humans Known As Customers have joined
forces with The Robots Who Reduce Information Asymmetry
and have become much more informed. Some of the information
they have curated is sourced from BoltonCorp itself through its
participation in trade associations and competitive advertising
campaigns and compliance with media outlets that evaluate
products and services. BoltonCorp seems to be complicit in its
own demise.
Answer one or both of the following questions.
Q1: Should you increase your efforts to hide information from
The Humans Known As Customers?
· If no, how will you explain your decision to the board of
directors that were hired to monitor your firm and defend
shareholder interests?
· If yes, how will you explain your decision to the news media
that report on your actions to the entire global society of The
Humans Known As Customers?
Q2: Should society make arrangements to alleviate problems
caused by The Robots Who Reduce Information Asymmetry?

· If yes, how would you go about getting laws passed that
enhance the power of corporations in a global environment that
seems to unanimously support the weakening of corporate
power?
· If no, how will you explain the impending global layoffs to
The Humans Known As Employees?
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.)
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

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

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

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

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).

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

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).
.
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
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

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
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

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 w ants 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.
https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf
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.
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 contributio ns 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 consistentl y
; 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:

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