1 1 1 A RESOURCE GUIDE FOR NURSES IN THE

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1
1
A RESOURCE GUIDE FOR NURSES IN THE HOSPITAL
SETTING TO IDENTIFY
PATIENT NEEDS AT DISCHARGE
By
Student name
A Project
Submitted to the Faculty of D'Youville
Division of Academic Affairs in partial fulfillment of the
requirements for the degree of
Master of Science
in
Nursing management and quality leadership
Buffalo, NY
[Month day, year]

Copyright © 2022 by student name. All rights reserved. No part
of this project may be copied or reproduced in any form or by
any means without the written permission of NAME .

PROJECT APPROVAL
Project Committee Chairperson
Name: ______
__student name
__________________________________________
Signature:
_____________________________________________________
_____
Discipline:____
___Nursing___________________________________________
_
Project Defended
On
[Month Day, Year]
Abstract
The project problem states, "How can nurses provide additional
support for elderly patients when their main concerns revolve
around the home as a place of fear for their return?" Due to the
nature of the nursing workload in the hospital setting, discharge
planning tends to be pushed aside due to other priorities.
However, it is important that as much as patients are cared for
in the inpatient setting, they also need proper preparations for
their home setting. The project's purpose is to provide

assistance for nurses and develop a nursing resource guide with
regards to important points needed in discharge planning.
Dorothea Orem's Self-Care Deficit nursing theory (Orem, 1991;
Orem et al., 2003) is utilized as the theoretical framework for
the project. Five content experts will review the resource guide
for content validity.
Table of Contents
Chapter
I. PROJECT
INTRODUCTION……………………………………..…....8
Statement of Purpose 9
Theoretical Framework 9
Initial Review of the Literature 18
Significance and Justification 31
Project Objectives 31
Definition of Terms 32
Project Limitations 32
Project Development Plan 32
Plan for Protection of Human Subjects 33
Plan for Project Evaluation 34
Summary 35
II. REVIEW OF LITERATURE
……………………………………...... Summary
…………………………………………………………......
III. PROJECT DEVELOPMENT
PLAN...………………………………. Project Setting and

Population………………………………………..
Content Expert Participants
…………………………………….……. Data Collection Methods
…………………………………....….…….
Project Tools
……………….……….…….…………………………. The
Protection of Human Subjects ………………………….………
Summary ……………………………………………………………..
IV. PROJECT EVALUATION, IMPLICATIONS, AND
FUTURE RECOMMENDATIONS
………………………………………...................................
…........
Project Evaluation
…………………………..…………….….……..
Implications for Future Practice
………….………………….……..
Future Recommendations
……………………………………….....
Summary
…………………………………………………………....
References
……………………………………………………….....36
Appendices
………………………………………………………....41
List of Appendices
Appendix
A D’Youville Patricia H. Garman School of Nursing Full
Approval Letter

…………………….…........................................................
...............41
B Letter of Intent
…………………………...…………………………42
C Evaluation Tool
……………………………………..……………...44
D Resource
Guide................................………………………………..
E Survey tool results in
graph………………………………………….47
Chapter I
Hospital readmission of recently discharged patients is a
common, yet undesirable, occurrence. The goal is that when
patients are discharged from the hospital, they stay home
because having a reduced number of readmitted patients in
hospital settings reflects the higher quality of patient care
provided by the health care system (Dols et al., 2018).
However, it is also quite common to see patients, especially
those with advanced age, admitted to hospital with the diagnosis
of "failure to cope", as seen by this project author at the
bedside. The literature also provides information on patients
being readmitted to the hospital weeks or months post
discharge. One such study by Yen et al. (2022) provides results
indicating that 14.3% of their 300 patient sample (all above 80
years of age) were readmitted to the hospital 30 days after

discharge. This percentage also increased to 19.7% and 43% at
60 days and one year post hospital discharge, respectively.
Verna et al. (2022) and Ayatollahi et al. (2018) relate hospital
readmissions to patient comorbidities and diagnoses involving
cardiovascular disease, diabetes, respiratory illness, and kidney
disease. Verna et al.'s (2022) findings also relate hospital
readmission to a shorter hospital stay, which causes a return to
the hospital within 10 days of their recent discharge. When
patients are discharged and readmitted back to the hospital, it
makes one wonder why they are happening and what else can be
done to prevent readmissions. Nurses are the health care
profession that spends the most time with patients at the bedside
from admission to discharge, hence nurses can have the most
impact on patient needs.
This raises the question: how can nurses provide further
support for elderly patients when their main concerns revolve
around the home as a place of fear for their return? Dorothea E.
Orem's self-care deficit nursing theory (SCDNT) is the
theoretical framework that fits this area of concern. Through the
guidance of an initial review of the literature, this project aims
to provide clarity and background on the needs surrounding
discharge planning; what nurses can do; and how nurses can be
supported in doing so. Statement of Purpose
The purpose of this project is to develop a resource guide
for nurses in the hospital
setting to identify the patient's needs at discharge. Theoretical
Framework
Dorothea E. Orem's (1991) self-care deficit nursing theory is
utilized as the theoretical framework for the development of this
project. A brief overview of the theory is presented as well as a
discussion regarding how the theory was utilized to guide the
development of the project. In addition, Orem's (1991)

theoretical definitions for nursing’s four metaparadigm concepts
(nursing, health, person, and environment) as well as the Project
Author’s operational definitions for nursing’s four
metaparadigm concepts will be presented. Self-Care Deficit
Nursing Theory
Dorothea E. Orem's impact on nursing reflects on her work
towards developing and establishing her self-care deficit
nursing theory (SCDNT). Her theory development began with
the reflection question: "What condition exists in a person when
that person or a family member or the attending physician or a
nurse makes the judgment that the person should be under
nursing care?" (Orem, 1991, p. 61). In the fourth edition of her
book,
Nursing: Concepts of Practice, Orem explained that the
journey towards her theory development began with the need to
define nursing, identify when a nurse is needed, and the support
a nurse can provide a patient.
The self-care deficit nursing theory is divided into
three theories: the
theory of selfcare; the
theory of self-care deficit; and the
theory of nursing system (Orem, 1991). In order to
understand the theory, it is important to first have an
understanding of its major concepts:
selfcare, self-care agency, self-care demands, nursing
agency, self-care deficit, and
conditioning factors (Orem et al., 2003)
.Self-care is defined as the person's general act of
providing necessary everyday needs for themselves in order to
maintain human function and well-being.
Self-care agency is the person's learned competence to
practice self-care.
Self-care demands refer to the actual actions that are
necessary for the person's body to maintain health, e.g., feeding

oneself independently. Without these actions, the person's
health will deteriorate.
Nursing agency refers to the nurse's ability to assess
and provide a care plan that matches the needs of the patient.
Selfcare deficit is the lack of the person's
self-care agency to provide for the
self-care demands. Conditioning factors refer to
elements that can affect a person's ability to practice self-care,
such as age, gender, developmental state, sociocultural
influences, lifestyle habits, and health status.
The Theory of Self-Care
The
theory of self-care centralizes on the idea of a person
who is able to provide requirements that are essential for the
maintenance of life and function. Orem called these
requirements "universal self-care requisites" and they refer to a
person's basic needs, including sufficient intake of air, water,
and nutrients
, elimination of body waste
, providing the body the balance between activity and
rest
, privacy and social interaction/human relationships
, and prevention of illness (which also includes seeking
medical assistance when ill) (Orem, 1991, p. 126). As an
alternative to self-care, Orem (1991) identifies that there are
individuals who are not able to provide their own self-care as
part of their baseline function, e.g., children or seniors.
Therefore, Orem referred to this as dependent care, where
someone who is capable will be the person to provide self-care
actions to the individual who is dependent.
Orem (1991) provided assumptions and propositions within
the theory of self-care.
According to Orem (1991), the theory of self-care assumes that
all individuals have the possibility to learn how to develop and
provide self-care as well as dependent care. This results in the

assumption that one can learn to see recurring patterns of needs,
allowing one to form a self-care and dependent care routine
towards the repeating self-care or dependent care demands. The
theory also assumes that self-care requisites are met with the
influence of one's culture and social influences. Therefore, it
assumes that the action of self-care and dependent care depends
on the person's preference in how they respond given a certain
event.
The theory of self-care, as per Orem (1991), provides the
proposition that regularly practiced acts of self-care will be
applied effectively and successfully. It also proposes that the
act of self-care is in response to the best of the person's
knowledge of how the self-care needs can be met. Self-care also
involves the use of materials needed to complete the act of self-
care. It also proposes that externally projected self-care is
observable (e.g., the ability to mobilize independently), while
those that are internally projected can only be observed through
collecting information from the person (e.g., the person's
motivation to practice mobility to gain progress). Another
proposal under this theory explains that self-care that is
routinely done over time forms a
self-care system where the person will be able to
identify and predict how their actions will result in their self-
care. It also allows the person to learn to adjust and adapt to
change, e.g., learning and taking new medications as prescribed.
The Theory of Self-Care Deficit
The
theory of self-care deficit explains how nursing is
needed by the person who is unable to provide self-care (Orem
et al., 2003). Orem (1991) explains that the person's inability to
provide self-care could be due to issues related to their health
or brought forth by interventions for their health care. Examples
of this include weakness from treatment such as chemotherapy
that disables a person's level of energy and requires them to
take medications that counteract the side effects of treatment.
Another example is that of surgery. Depending on the type of

surgery, multiple organ systems can be affected as well as the
person's mobility. Nursing is essential for these patients in
order to accommodate the inability of the person to provide
specific self-care practices.
Assumptions that are identified by Orem (1991) within the
theory of self-care deficit are divided into people who have the
capability to provide self-care and those who are relying on
dependent care. For those who can have the ability to provide
self-care, this theory assumes that a person should be able to
manage their self-care in a stable environment but also be able
to identify their limits in certain situations. It also assumes that
a person's participation in self-care depends on their values and
outlook toward their health and life, cultural beliefs, and
influences from their social circle. For those who are dependent
on their care, it is assumed that the health care system and
available community resources will provide assistance for the
person, such as nursing care, if needed. It also assumes that if a
person is a part of a facility, for instance, a longterm care home,
this becomes the patient's main means of acquiring the care that
they need. The propositions provided by Orem's (1991) theory
of self-care deficit include the idea that those who are able to
participate in self-care or dependent care are under the
influence of the conditioning factors mentioned above. The
theory also proposes that nursing is necessary when the self-
care ability of the person is not able to meet the self-care
demands. It also adds that nursing is necessary when there is
anticipation that the patient will not be able to practice selfcare
immediately e.g., post-surgical care. The Theory of Nursing
System
The theory of nursing system establishes nursing agency and
the structure of nursing the patient needs and is divided into
three types
: wholly compensatory, partially compensatory and
supportive educative system (Orem et al., 2003).
Wholly compensatory defines the inability for self-care

agency to meet self-care demands. The patient is unable to
practice self-care that meets their body's needs therefore this is
when nursing is needed as a temporary substitute to assist the
patient with their self-care needs until they are able to attend to
them themselves.
Partially compensatory is identified when the patient is
able to practice some self-care activities, is not fully dependent
on the nurse and the nurse's role changes to an assistive role.
Supportive educative system requires the more minimal
amount of nursing assistance as the nurse takes on a more
supportive role where they are there to supervise or guide the
patient to further strengthen their self-care agency.
The assumptions provided by Orem (1991) toward the theory of
nursing system describes the role of the nurse as part of patient
care that is time-limited as long as the patient needs assistance
in self-care activities until they are able to practice them
independently. The theory also includes in its assumption that
nursing is a profession that acts within its scope of practice
under a governing body that provides a focus to the profession.
Propositions suggested by Orem (1991) to reflect the theory of
nursing system include the relationship between the nurse and
the patient, who has specific self-care requisites but cannot
meet the demands. Nurses in turn, attend to the patient by
identifying the patient's selfcare requisites that need assisting
and formulating a care plan to support the patient into
practicing independent self-care. Through assessment, the nurse
is able to know the patient's capabilities regarding the patient's
self-care agency therefore will increase or decrease the amount
of support given to the patient. Lastly, the theory proposes that
the nurse and patient work collaboratively in order for the
patient to improve towards meeting their own self-care demand
through practice of self-care as independently as possible.
Graduate Student Project and Orem's Theory
With the advancement of science and medical
interventions, comes prolonged life for the general population.

With that said, humans are living longer, resulting in patient
populations reaching ages in their 100s, as seen by this writer at
the bedside. From this writer's nursing experience, while the
healthcare system provides great care for illness and treats the
cause of disease, it has not solved the emerging issues regarding
the coping mechanisms of elderly patients as they continue to
live their lives at home. The goal of medicine is to treat illness,
yet patients come into the hospital system with the admitting
diagnosis of "failure to cope." This brings back the question for
the project: How can nurses provide further support for elderly
patients when their main concerns revolve around the home as a
place of fear for their return? This issue fits
well with Orem's self-care deficit nursing theory because the
patient's inability to cope at home translates to their inability to
practice self-care. The elderly person becomes someone who
identifies with
dependent care and becomes admitted to the hospital
due to "failure to cope."
Self-Care Deficit Nursing Theory and Nursing's
Metaparadigm
Orem did not directly relate her theory to the metaparadigm
concepts of
person, environment, health, and nursing, but she
clearly communicated in her writings how each contributed to
her theory's meaning. According to Orem's (1991) self-care
deficit nursing theory, understanding the
person is to understand that they initially
refer to an individual who is able to provide basic
human needs for themselves (self-care agents) through learned
experiences, enabling them to practice self-care. The
person can also refer to someone who is of dependent
status where they are unable to practice self-care as they are
incapable of doing so and therefore rely on family or their
caregiver to provide their self-care actions for them. The
person is also identified as someone who is unable to
practice self-care due to medical or health care intervention

reasons (Orem, 1991). The
person becomes a patient who needs assistance,
training, and guidance to be able to practice self-care again with
the help of nursing. For the purpose of the project, the
person is operationally defined as the patient who is
receiving care due to their inability to cope and function at
home. The
person could be in a position where they are unable to
practice
self-care with or without support and hence is admitted
to a hospital to seek assistance. The main issue for these
patients could simply be a lack of energy or being too weak to
mobilize and participate in self-care activities. The patients may
or may not have underlying medical issues that are causing a
lack of participation in their activities of daily living.
Although the
person refers to the individual, Orem (1991) makes it a
point to emphasize that the
person is not isolated by the self. Orem (1991) explains
that humans should be seen as functioning "biologically,
symbolically, and socially" as someone who comes from a place
with their own responsibility and role towards others (p. 181).
This introduces nursing's metaparadigm concept of the
environment. Orem (1991) explains that a
person is consistently linked to their
environment. Individuals exist within their
environment, which Orem explains as features that are
physiochemical, biologic, socioeconomic-cultural
, and
community in nature (Orem, 1991). Physiochemical
features of the environment refer to the air, pollutants,
weather, and the status of the earth's stability. Biologic features
involve animals, including the person's pets, infectious
organisms, and other people or animals that can be agents of
bacteria or diseases. Socioeconomic-cultural features refer to

the
person's family, their role and relationship with their
family, cultural values, dynamics, as well as beliefs that could
affect their decision making. Community
refers
to a person's access to health care services, resources
for cultural and healthcare needs, as well as accessibility.
Overall, it is important to have an understanding that their type
of environment affects how patients perceive their care and the
decisions they make regarding their care plan. E
nvironment is operationally defined, for the purposes of
the project, as a location that begins at the hospital and ends at
their home. Cultural beliefs, social support, financial status,
educational level, and accessibility of health care resources and
availability from the area they live in are also vital information
that is important to understand as the person is transitioned to
their
environment. Home can be defined as their place of
residence, whether it is in an apartment, house, long term care
home or retirement home where they may or may not live alone.
Orem (1991) sees
health as an element that can affect a
person's ability to practice selfcare. This is because
Orem (1991) views
health as synonymous with
"wholeness" and a change in this structure would be an
"absence" toward one's
health (p. 179). Orem (1991) also explains that
health is not the responsibility of one individual.
Health is a societal responsibility, because the mental,
interpersonal, and physical aspects of
health are all linked to the
person. When one becomes ill, it is not always possible
to focus only on healing and treatment. The person's
environment becomes a factor that plays into the

patient's ability to attend to their
health. If they are the sole breadwinner of their family
or they are the primary caregiver of their sick relative, it
becomes difficult for them to focus on their health due to the
circumstances of their responsibilities. Therefore, this places a
demand on the societal responsibilities toward a person's health
and involves necessary assistance that can be provided in order
for the individual to focus and become an independent self-care
agent once more.
Health is operationally defined as the person's
subjective view of themselves when faced with illness or a
deficit in their ability to function. It is important to understand
how the
person defines
health and what is most important to them, as well as
their goals.
Health should be discussed with the person's caregiver
as well (if possible) in order to properly communicate goals for
home and the reality of the elderly patient's own capability to
provide self-care. This writer agrees with Orem's definition of
health as a societal responsibility where assistance
towards one's wellness journey also depends on the
responsibilities and services that are available to provide
assistance for them. It will be difficult for a patient to return
home if there are no available resources to help them be
managed at home. Hence, it is the nurse's role to have an
understanding of not only the patient's current state but also
their social history.
Orem (1991) sees the metaparadigm of
nursing as synonymous with her concept of
nursing agency, where nursing is necessary as a
complement to a patient's inability to practice self-care. The
presence of nursing allows the person to appropriately rely on
the nurse as someone who can provide a care plan that adjusts
to the patient's improvement or decline and provide assistance

throughout their health care journey.
Nursing should have an understanding of the
person as someone who comes with certain cultural
values and beliefs that can affect their outlook on health and
wellness. Orem (1991) explains that nurses and their patients
should work together and form a good working relationship
where they have an understanding of the goals that meet the
needs of the patient while keeping in mind what is most
important to them in their
environment.
Nursing is operationally defined in the project as those
in the nursing profession that approach patient care with a
holistic perspective. The patient is not to be seen as an
individual who is simply admitted for limitations in their
physical function. The role of
nursing proves effective when they have a better
understanding of the patient and how the patient perceives their
care. If the patient is unable to make their own decisions due to
impairment in their cognition, it is part of the nurse's role to
communicate with the patient's caregiver (someone who is
providing
dependentcare) to understand the patient's capabilities,
wishes, and concerns.
It is also important for the nurse to present information to the
health care team regarding the patient's situation at home and
consult with the proper allied health professions to further
assist in the patient's potential need for health care support once
they return home. Initial Review of the Literature
A review of nursing and health related literature was conducted
to explore discharge planning using the following keywords
both singularly and in multiple combinations:
discharge planning, nursing, research, study, elderly, discharge
preparedness, community nursing, and

self-care. Databases searched, limited to the years 2017
and 2022, will include, CINAHL Plus with Full Text, EBSCO,
Google Scholar and the D'Youville library to loan articles
through interlibrary loan. The search is limited to the years
2017 to 2022 to ensure that current evidence-based literature is
reviewed and summarized for the purpose of this project. A
summary of the review of the literature is presented.
Patient Attitudes Toward Self-Care and Discharge
Planning
There are dynamics that define how a patient views
their hospital discharge planning. Some might find the process
easy and simple as they are now ready to return to their usual
routine and practice self-care, but other patients might find the
process challenging. One would assume that achieving safety at
home could be a challenge or a cause of fear for both the
patients and their caregivers. A study by Schreiner and Daly
(2020) provides clarity on this assumption in that they found
that age is not an indicator of a patient feeling "treatment
burden" or pressure regarding the amount of care they would
need on a daily basis due to medical conditions (p. 158).
Schreiner and Daly's (2020) findings indicate that if patients
receive support from family or caregivers regarding their care,
their perception of their care needs does not reach a high level
of treatment burden but only a moderate amount. On the other
hand, this does not mean that there is less treatment burden as
long as one has support. Evidence from the study indicates that
patients' levels of treatment burden increase during their
discharge planning process as they transition from hospital to
home. Having multiple chronic illnesses is also an element that
increases a patient's treatment burden, but ultimately, those who
receive support in their daily care have shown a decrease in and
a lower level of perceived treatment burden. However, this does
not specify the quality of support provided by the caregiver.
Relying on caregivers can also have a negative impact on a
patient's adherence to their care needs. Qualitative data from
Beckner et al. (2021) reveals that patients who rely on

caregivers are also at the caregiver's mercy. Some patients in
the study are unable to properly take their medications because
the caregiver had possession of the medications, did not fill the
prescription due to unavailability, or simply a lack of education
about the medications' importance. At the same time, when
patients are less reliant on others for care, their personalities
and attitudes toward their own care play a role in home
selfmanagement. Results in Beckner et al.'s (2021) research also
provide information about this. Some patients in the study
refused to be taught by nursing staff because they preferred to
hear from doctors, or they disagreed with the provider's
decision to discontinue certain medications, so they continued
to take them. Medication cost also presents a barrier towards
following medication administration instructions, as does a lack
of education on the medications, transportation to fill the
prescription, and, in some cases, pharmacy errors.
A patient's place within certain social demographics
also plays a part in how they may perceive their hospital
discharge and health management afterwards. Study findings in
research by Al-Maskari et al. (2021) show that of the post-op
patients who were part of the sample, those who have higher
levels of education and are currently working tend to show
priority on learning about their hospitalization and discharge.
Males and those who are married tend to veer towards learning
more about the details of physical activity, while females tend
to veer towards learning about medications and other details.
Additionally, those who have a higher income tend to prioritize
learning about function, mobility, and physical activities
compared to those who make less. Culture also plays a role in
prioritizing certain health management practices. In a study by
Tawalbeh et al. (2020), they found in their results that a
patient's ability to recognize the importance of certain health
practices depends on ethnic and cultural practices. Specifically,
in Tawalbeh et al.'s (2020) study, patients who were taught
heart failure self-care strategies were easily able to practice a
low-salt diet, do some physical activities, and attend their

doctor's appointments. However, the least followed self-care
behaviors included practicing illness avoidance, checking for
edema, such as ankle swelling, and doing at least 30 minutes of
exercise per day. The researchers found that the sampl e in the
study did not understand the importance of exercise due to the
nature of the culture of the population. However, in addition to
the information from the study by Al-Maskari et al. (2021),
Tawalbeh et al.'s (2020) research also includes evidence that
those with high income and education tend to show more
interest in learning about health maintenance. Moreover, being
of a younger age, living with more people at home, and not
following other traditional treatment regimens also relate to a
higher interest in learning.
In the hospital setting, there is the factor of the patient's
perception of discharge readiness. Baksi et al.'s (2021) study on
the examination of this topic reveals that patients who present
with more preparedness and readiness for discharge are those
with higher levels of education, which aligns with the results in
Al-Maskari et al.'s (2021) and Tawalbeh et al.'s (2020) studies.
Furthermore, satisfaction with the nursing care they receive,
having support at home, and being male all contribute to
discharge readiness (Baksi et al., 2021). Those who live alone,
are single, have a lower level of education, and have longer
hospital stays, on the other hand, have lower levels of
confidence in their discharge.
Outside of the patient's willingness or unwillingness to
learn self-care at the point of discharge, a patient's ability to
learn and follow health management education also plays a part
in the patient's capability to provide self-care in their home. In
the hospital setting, patients are not only presenting with a
pattern of longer hospital admissions (i.e., an average length of
stay of 26 days in 2013 compared to 28 days in 2015), but
patients are also presenting with more cognitive and functional
impairment or physical impairment and depression compared to
previous years (Popejoy et al., 2021). Cognition is a critical
issue when it comes to the discharge process, especially for

patients who have dementia. The research findings by Prusaczyk
et al. (2019) explain that patients with dementia tend to have
functional impairments that require them to be more wheelchair
dependent, showing support for the study results by Popejoy et
al. (2021). Patients with dementia are also less likely to report
accurate past medical histories, retain discharge-related
teaching, or receive discharge education at all due to their
known memory issues, resulting in hospital readmission or
being discharged to another facility (Prusaczyk et al.,
2019). Nursing and Discharge Planning
Nurses are often the last health care professionals a
patient sees when leaving the hospital during discharge
(Davisson & Swanson, 2020a). With this knowledge, it is safe
to identify that nurses should have a main role in discharge
planning for patients. However, this is not always the case.
Studies done by Davisson and Swanson (2020b) and Hayajneh et
al. (2020) on nurses' positions towards discharge planning show
a general disapproval of nurses' participation in discharge
planning. According to the nurses, many of the barriers to
discharge planning in the results are due to a lack of time,
which can be worsened by the existence of a language barrier, a
high patient load, and assignment acuity, resulting in nurses
stating that urgent tasks would be prioritized over discharge
planning. Nurses in Davisson and Swanson's (2020b) study also
voice that they do not feel a structured process of discharge
planning guided by the hospital's policy and discharge planning
only adds more responsibility to their role. General results from
Hayajneh et al.'s (2020) research find that nurses have little
knowledge of discharge planning in all aspects, including goals
of discharge planning, who can and should be involved, the role
of the patient care manager, and who is best to assess the
patient's needs toward discharge planning. The nurses in the
study rely on the physicians regarding discharge planning and
instructions, therefore causing the impression that discharge
planning is not within the nursing scope of practice and that
they do not have the autonomy to practice discharge planning.

Contrary to the results of Hayajneh et al.'s (2020)
study, there is acknowledgement from other nurses regarding
discharge planning. A nurse in Davisson and Swanson's (2020b)
study acknowledges that assisting in discharge planning should
start at the point of admission. Another nurse states, "We know
what we should be doing. We know what it means for the
patient. What is it that we need to accomplish on this admission
to make this patient not come back so soon? We need to work
on that so that we don't go in as individuals, going in as a team,
pulling on the same string "(p. 4). This shows that there is an
understanding of the importance of discharge planning but also
a lack of unity as a team towards discharge planning. Further
concerns brought up by the nurses in Davisson and Swanson's
(2020a) study include the lack of communication as shown by
sudden, unplanned discharges, whereby by that point, teaching
becomes a barrier for the patients as they tend to only focus on
wanting to leave the hospital, leaving no time for the nurse to
provide discharge education due to patient dismissal.
Despite the fact that the studies above show a negative attitude
toward discharge planning, studies also show that this is not the
consensus. Hayajneh et al. (2020) identify that nurses who have
a lower number of patients, work in teaching hospitals and
within certain specialty areas such as the intensive care units
and acute wards, tend to have more knowledge and positivity
toward discharge planning. Due to the nature of a nurse's
routine, medication teaching is also seen as an important part of
discharge planning by the nurses (Hayajneh et al., 2020).
Davisson and Swanson (2020a) also provide their study results
on the importance of relationships nurses build with their
patients. Nurses voice that having good rapport with their
patients helps them want to look further into the patient's
discharge barrier and reasons for frequent readmissions. Newer
nurses also report that due to their lack of experience, it feels
more proper to rely on the more experienced nurses' knowledge
to provide teaching to patients. AlMaskari et al. (2021)
expanded on this by complementing that as nurses gain more

experience through years of practice, they tend to provide
teaching on specific details such as anatomy and physiology
concerning the patient's condition, when to seek medical help,
and resources for the family to learn post-discharge.
It is important to understand that although there are
reasons why nurses might not participate in or acknowledge the
importance of discharge planning, there are also reasons why
they might do so. At the same time, there are also situations,
such as a lighter workload and level of nursing experience, that
allow nurses to support discharge. Discharge Assessment Tools
The literature discusses multiple tools to help guide discharge
planning for the health care team. One study by Kawar et al.
(2021) focuses on the addition of a mobility ambulation
assessment tool into the electronic health record system as part
of the nurses' routine documentation. This tool was received
well and was also accepted by the nurses. The nurses indicated
that this tool made it easier during transfer of accountability
reports such as shift change. The tool also allows the nurses to
anticipate needs and identify those who would need further
intervention as well as discharge planning because it shows the
patient's progress and decline in mobility. Similar results were
found in studies using another tool called the Readiness for
Hospital Discharge Scale (RHDS). Bobay et al.'s (2018) study
results find the RHDS tool effective as it provides nurses the
guidance needed in order to assess a patient's readiness to go
home as they reach the end of their hospital stay. The study
finds the tool reliable and also predictive of those at risk of
hospital readmission or return to the emergency department
within 30 days of discharge. RHDS also allows studies such as
that of Baksi et al.'s (2021) to gather data pertaining to
readiness for discharge in relation to social demographics of
patients as per a previous discussion above.
Frailty risk score (FRS) is also a risk assessment tool
that is seen in the literature as effective in aiding in needs
prediction. Much like the mobility assessment tool, this is also
incorporated into the electronic health records as part of nursing

documentation. Results from a study by Lekan et al. (2021)
directly relate a patient's FRS to the risk of hospital readmission
within 30 days of discharge. A later study by Lekan et al.
(2022) adds the ability of FRS to also predict patient mortality
in the hospital setting. Both studies provide emphasis on the
importance of the FRS as a guide for nurses and other health
care professionals to better consider who would need further
attention towards better interventions and discharge planning,
while also including the patient's caregiver in the process, if
applicable.
On a more specific note relating to the ability of
patients to apply self-care, Grenier et al. (2022) introduce the
use of the performance assessment self-care skills (PASS) tool
in order to asses a patient's ability to perform their activities of
daily living (ADL). This study focuses on the occupational
therapy (OT) profession, where the OTs' use of the tool has
shown effectiveness in predicting the risk of hospital
readmission and emergency department visits. Specifically to
PASS, a patient's inability to use the telephone and take their
medications independently is found to be directly related to the
high risk events for the patient after hospital discharge, causing
a need for hospital readmission. Specific results within the tool
also reveal that the ability to prepare meals and having physical
disabilities (without cognitive impairment) do not indicate a
risk or increase in risk for hospital readmission.
While the aforementioned assessment tools help predict
the risk of hospital readmission or mortality within the hospital,
there is a program found in the literature that is specific to the
discharge planning process. The Reengineered Discharge (RED)
program has shown promise in the literature by Popejoy et al.
(2019) and later on also by Popejoy et al. (2021). The program
takes into account language preference, ensuring follow -up
appointments are set up, medical equipment and outpatient
needs are organized, teaching and education is done with
patients and families with an assessment to confirm their
understanding, making sure that patients know what to do when

faced with an emergency or issues at home, and telephone
communication regarding discharge plans. The level of
understanding of the patient's home location, culture, and
language is an important part of ensuring that when education is
given to patients going home from the hospital, each education
plan is done so with an individualized understanding of the
patient and the environment they will go home to, if not, risking
hospital return (Davisson & Swanson, 2020;
Dols et al., 2018). Both of the studies by Popejoy et al. (2019;
2021) used skilled nursing facilities (SNF) to implement the
program with the goal of improving the discharge planning
process for patients ready to go back home to their own
community. The results of Popejoy et al.'s (2019) study show
some promise. However, the program was not as well received
by the nurses, contrary to the authors' prediction. Barriers were
mainly related to the implementation of change in the facilities
and a lack of support from the leadership level. The succeeding
study continues to pursue the implementation of the RED
program into SNFs and has shown better staff acceptance
through a slower implementation process (Popejoy et al., 2021).
This study emphasizes the importance of management support,
as change will not occur without the support of those in the
leadership level, even if staff try to engage in change.
Overall, not all new implementations of tools or
programs can be expected to be successful. However, it is
important to understand areas of improvement from study
results, how the change was received, and what elements made
it work or not work. Ultimately, without support from staff and
management, promotion of change will continue to be a
challenge and issues with discharge planning will continue to
develop as the population continues to show more cognitive and
functional impairment as well as longer hospital stays (Popejoy
et al., 2021). Supporting the nurse at discharge planning
In order for nurses to provide support for their patients
during discharge, nurses should also be supported in order for
them to do what they do best with the best quality they can

provide. Support can be in the form of leadership support, allied
health involvement, education provided, and having the
knowledge of resources that would benefit the patient.
As previously mentioned in the research study by
Popejoy et al. (2019; 2021), it is difficult to implement new
programs that support change and progress without support from
management. The absence of support creates a barrier and
reduces the quality of discharge planning. It is the role of those
in management to ensure adequate staffing is present and, by
having the ideal nursing workload compared to a heavier
workload due to short-staffing, will help elevate the views of
nurses toward discharge planning and will also acquire better
cooperation toward its implementation (Hayajneh et al., 2020).
According to research, involving the multidisciplinary team
(e.g., social worker, physiotherapist, occupational therapist,
dietician) in discharge planning is also important due to their
added perspective, completing a full overall knowledge about
the patients from the medical, social, and physical concerns
they may have (Popejoy et al., 2021; Grenier et al., 2022). For
example, Grenier et al.'s (2022) study not only supports the use
of the PASS tool, as mentioned previously, but its results also
emphasize that the team needs to rely on OTs and understand
that their knowledge and insight are evidently useful in the
prediction of hospital readmissions. Therefore, the researchers
suggest that if OTs voice their concerns about a patient's safety
at home, homecare services need to be in place for the patient as
they are at a high risk for events at home that would cause a
hospital readmission or visit to the emergency department.
Research such as that of Popejoy et al. (2019; 2021)
finds that there is evidence for nursing staff acceptance of new
practice implementations when they receive education.
Otherwise, there will be resistance to change. In order to
support nurses with discharge planning, it is important that they
are given proper guidance in order to apply this skill in
practice. This guidance can be in the form of education
provided to nurses, such as that of the teach-back method. In a

study by Scott et al. (2019), the researchers identified that the
teach-back method encourages patients to not only receive
information from their health care team but also allows them to
participate in their care and education. During the study period,
the participating nurses were given education sessions on how
to properly relay their teaching to patients, such as how to
speak clearly, access education materials with minimal medical
jargon, and ask patients to repeat what has been taught in their
own understanding (teach-back). The teach-back method allows
the nurse and patient to learn what the patient understands and
needs clarification on. This study provides evidence that the
teach-back method is a useful teaching skill that nurses can
apply to ease the stress (i.e., treatment burden) of patients as
they transition from hospital to home. Another study finding
provides an example that providing education through
simulation activities within a learning environment increases a
nurse's self-efficacy in practice (Genuino, 2018). Genuino's
(2018) study results indicate that a nurse's age, experience, and
further education achieved does not affect a nurse's level of
self-efficacy when it comes to providing patient education about
their diagnosis and self-management at home (e.g. heart failure
and chronic obstructive pulmonary disease management).
Knowing what resources to refer patients to is advantageous for
successful discharge planning as it enables patients to discuss
their care. For example, Whitehouse et al.'s (2020) study
validates the efficacy of a diabetes self-management education
and support (DSMES) program delivered in the community
through telehealth. The study recognizes that the postdischarge
period of a patient is not only a moment of the highest risk of
rehospitalization but also the time that provides the ability to
deliver the most education to patients and their caregivers. As a
result, providing information about community resources to
nurses at the bedside not only reduces the likelihood of hospital
readmission but also empowers patients in their own care.
Without a nurse's ability to properly provide a patient the
education they need to manage their health at home, there is no

successful discharge planning and patients will be at a higher
risk for readmission to the hospital. Readmissions, in turn,
decrease a patient's quality of life, which is proven to directly
relate to a patient's readmission rate post-hospital discharge
(Leavitt et al., 2020).
As previously mentioned in Davisson and Swanson's (2020)
study, discharge planning should start at the point of admission.
In their study findings, Beckner et al. (2021) indicate the
importance of linking patients to appropriate home care services
(e.g., nursing support at home with medications) and how it
should start at the bedside. Nurses can start the education
delivery to patients and provide information to the home care
services in the community at discharge in order to assist with
continuity of care at the patient's own home. The literature also
stresses the involvement of caregivers in the discharge planning
process to help ease the patient's transition back home. While it
was previously mentioned by Beckner et al. (2021) that there
are disadvantages to the dependency of patients with their
caregivers, there are also studies that prove otherwise. A study
by Agarwal et al. (2020) recognizes that the cognitive
impairment of patients has the tendency to worsen their heart
failure management, which increases symptoms and admission
rates. This study looks into the involvement of caregivers in
relation to this issue and reports that patients in the study who
had caregiver involvement during their hospital discharge
process have a lower readmission rate 30 days after hospital
discharge. This result compares to the low readmission rate of
patients with no cognitive impairment and who are able to
manage their heart failure management at home. In comparison
to Agarwal et al.'s (2020) study, Lin et al. (2018) also
complement the prior study's results with the perspective of
caregivers. Lin et al. (2018) examine the helpfulness of
involving patient caregivers in a discharge planning program
and how it affects the caregiver burden level for patients with
schizophrenia. The study involves caregivers through needs
assessment tools, providing and connecting them with resources

in the community, education on their family's mental health, and
assessment of the caregivers' own level of stress and health
status. The study shows that although there is a form of respite
for caregivers when their loved ones are admitted into the
hospital, involving them in discharge planning proves effective
in terms of decreasing their own caregiver burden levels and
improving their ability to better take care of their family once
they are discharged from the hospital. This adds an element of
aid to decrease the patient's chance of being readmitted to the
hospital as well as provides a counter to the disadvantages of
caregivers previously identified by Beckner et al. (2021).
Prusaczyk et al.'s (2019) study also supports this finding with
the same results involving a decrease in caregiver burden
through education on discharge planning with their families
with dementia. Lastly, Baksi et al. (2021) recommend from their
study findings that it is important for the health care team to
involve patients' families and caregivers in discharge planning
(e.g., providing education materials such as brochures, videos,
and pamphlets) as it helps patients feel confident and ready for
hospital discharge. Assisting nurses with discharge
planning involves the provision of proper education for better
delivery of knowledge during the discharge planning process. In
order to have a successful discharge with a lower risk of
hospital readmission, nurses need to have proper training and
education but also have the knowledge of resources to
recommend to patients and their caregivers. It is also important
for nurses to know when it is appropriate to involve the
multidisciplinary team (e.g., occupational therapy team) to
better prepare the patient for discharge and the importance of
caregiver involvement for the patient's successful transition to
their home.
Significance and Justification
Findings from the initial literature review reveal that a lack of

knowledge exists in nursing and patient care practice regarding
discharge planning. Due to the nature of nursing workload,
discharge planning tends to be seen as a low priority among
other tasks (Davisson & Swanson, 2020b). The study by
Davisson and Swanson (2020b) shows that although nurses in
the sample see discharge planning as unstructured, they also
understand its importance. The nurses in the study understand
that proper discharge planning helps prevent hospital
readmission. Yet there are barriers such as time constraints and
lack of discharge timeline communication that cause a lack of
discharge education, let alone planning. Hence, the need for a
resource guide that can be used by nurses to start discharge
planning from the moment of admission in the hospital setting.
In order to identify a patient's needs at discharge, it is important
for the nurse to have knowledge of a patient's pre-
hospitalization capabilities at home. This can potentially cause
a ripple of involvement with other multidisciplinary teams who
can assist in helping to prepare patients for their eventual
discharge. This project is necessary because it can help provide
nurses a more structured discharge plan that is ongoing
throughout a patient's hospital admission regardless of a
possible increase in a patient's acuity or need for medical
intervention. Project Objectives
The objectives of this project are to:
1. Conduct an extensive review of the literature exploring
discharge planning using the following keywords both
singularly and in multiple combinations: discharge planning,
nursing, research, study, elderly, discharge preparedness,
community nursing, and
selfcare. Databases searched, limited to the years 2017
and 2022, will include, CINAHL Plus with Full Text, EBSCO,
Google Scholar and the D'Youville library to loan articles
through interlibrary loan;

2. Develop a resource guide; and
3. Have a panel of five content experts with extensive
knowledge and expertise in discharge planning evaluate and
critique the project for clarity, readability, applicability,
quality, organization, and evidence-based clinical relevance.
Definition of Terms
The following concepts are defined both theoretically and
operationally for the purpose of this project:
Caregivers
Theoretical Definition: People who assist a patient who is
unable to manage their own health care needs independently
(Schreiner & Daly, 2020).
Operational Definition: A patient's family, friend, or health
care provider that provides support and assists them in
managing their health care or activities of daily living.
Discharge Planning
Theoretical Definition: A process that needs to be started at the
beginning of a patient's hospital admission in order to organize
the essential preparations needed for patients to safely continue
their care at home (Hayajneh et al., 2020).
Operational Definition: A part of nursing duty that starts with
the assessment of a patient's capabilities and functions at home.
This is ongoing throughout the patient's hospital admission and
requires collaboration from the health care team with the goal
of preventing hospital readmission.
Limitations
The Project Author recognizes the following project limitations:
1. The implementation of the resource guide is not within the
context of this project;
2. The resource guide is developed in the English language only
and may benefit a more culturally diverse population if written

in additional languages
Project Development Plan
A detailed topical outline of the resource guide content is
created based on the extensive review of evidence-based
literature and the theoretical framework used to support and
guide the development of the resource guide. After permission
is granted from the D’Youville Patricia H. Garman School of
Nursing, graduate faculty designee (Appendix A), five
professionals with knowledge and expertise in discharge
planning will be asked if they are interested in voluntarily
participating as an expert content reviewer for the resource
guide. The content expert panel will consist of three registered
nurses, and two coordinators with discharge planning
responsibilities. If interested, the Project Author will mail a
packet containing a Letter of Intent (Appendix B), a copy of the
Content Expert Project Evaluation Tool created by the Project
Author specifically for the project (Appendix C), a copy of the
resource guide (Appendix D), and a self-addressed stamped
envelope. The Letter of Intent will explain the project purpose
and instructions for completing and returning the Content
Expert Project Evaluation Tool to the Project Author. The
Content Expert Project Evaluation Tool contains six evaluative
items with space for narrative comments and suggestions.
Approximately 20 minutes will be required to review the
resource guide and to complete the Content Expert Project
Evaluation Tool. Content experts will be provided a self-
addressed envelope to return the Content Expert Project
Evaluation Tool to the Project Author. Once all evaluation tools
are returned to the Project Author, data will be analyzed and
reported narratively and in bar graph format. A summary of the
evaluation results including the findings of the six evaluative
items in the content expert project evaluation tool will be
provided to the content expert reviewers by postal mail. Plan for
the Protection of Human Subjects

Following approval from the D’Youville Patricia H. Garman
School of Nursing, graduate faculty designee (Appendix A),
five professionals with knowledge and expertise in the field of
discharge planning will be personally approached and asked to
voluntarily participate as a content expert in the review and
evaluation of the resource guide (Appendix D). Content experts
will be advised that participation or non-participation as an
expert reviewer will have no effect on their employment status.
The Project Author has a collegial, professional, and
nonsupervisory relationship with the content expert reviewers
thereby protecting the participants from any risk of coercion.
Content experts will be guaranteed confidentiality because
identifying characteristics will not be collected on the Content
Expert Project Evaluation Tool and because their names will not
be revealed anywhere in the project manuscript or in required
project presentations. Only the Project Author will know the
names of the content expert reviewers. Return of the completed
content expert Project Evaluation Tool (Appendix C) will
indicate implied voluntary consent to participate as a content
expert reviewer. Content experts will be advised that they will
not be able to withdraw from project participation once the
project evaluation tool is returned to the Project Author because
the evaluation tool will be returned without identifying
information. Returned Content Expert Project Evaluation Tools
will be stored according to the D’Youville Patricia H. Garman
School of Nursing protocol in a locked
drawer located in the Project Author’s home for a period of six
years and then destroyed. Plan for Project Evaluation
After obtaining full approval from the D’Youville Patricia H.
Garman School of Nursing (Appendix A), the Project Author
will mail a packet to each content expert reviewer containing
one Letter of Intent (Appendix B), one copy of the Content
Expert Project Evaluation Tool (Appendix C), one copy of the
resource guide (Appendix D), and one self-addressed stamped

envelope. The Letter of Intent will explain the project purpose
and instructions for completing and returning the Content
Expert Project Evaluation Tool to the Project Author.
The Content Expert Project Evaluation Tool will consist of six
evaluative items scored on a four point Likert Scale that ranges
from (1) Strongly Disagree, (2) Disagree, (3) Agree, and (4)
Strongly Agree. Space will be provided for narrative comments
and suggestions following each evaluative item. Evaluative
items will ask reviewers to rate the resource guide on clarity,
readability, applicability, quality, organization, and evidence -
based clinical relevance.
Approximately 20 minutes will be required to review the
resource guide and to complete the Content Expert Project
Evaluation Tool. Content experts will be given seven days to
complete and return the Content Expert Project Evaluation Tool
to the Project Author via postal mail using the self-addressed
stamped envelope included in the original packet. Likert scale
responses will be presented narratively and displayed in bar
graph format. Content expert suggestions and comments will be
analyzed for common themes and presented narratively. A
summary of the evaluation results including the findings of the
six evaluative items in the content expert project evaluation tool
will be provided to the content expert reviewers by postal mail.
Summary
Chapter I presented the project introduction, statement of
purpose, an overview of the theoretical framework guiding
project development, an initial review of the literature focusing
on the development of a resource guide for nurses in the
hospital setting to identify the patient's needs at discharge, the
project significance and justification, project objectives,
definition of terms, project limitations, the project development
plan, the protection of human subjects, the plan for project
evaluation, and a chapter summary. Chapter II will provide an
extensive review of the literature focusing on the development

of a resource guide for nurses in the hospital setting to identify
the patient's needs at discharge and a chapter summary. Chapter
III will discuss the intended project setting and population, the
content expert participants, data collection methods, project
tools, the protection of human subjects, and a chapter summary.
Chapter IV will discuss the evaluation of the project,
implications for future advanced nursing practice,
recommendations for future projects and research, and a chapter
summary.
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Appendix A
Patricia H. Garman School of Nursing
Full Approval Letter

Content Expert Letter of Intent
Dear Content Expert,
Hello, my name is nixxkkk I am a graduate student completing
a Master of Science in nursing degree at D’Youville College in
Buffalo, New York. Currently, I am developing a resource guide
for nurses in the hospital setting.
I am submitting the resource guide for your expert review and
evaluation. Recommendations and critique of this work in
progress will be taken into serious consideration during the
final revisions of this work. You are being asked to review and
evaluate the resource guide for clarity, readability,
applicability, quality, organization, and evidence-based
relevance. Your review of the resource guide should take
approximately 20 minutes of your time. The evaluation process
is completely voluntary and your refusal to participate will
involve no penalty or loss to you. Your responses will be kept
confidential and will be available only to me. If you choose to
participate, please return the evaluation tool within the next
seven (7) days using the enclosed self-addressed stamped
envelope. Consent to participate in the evaluation is implied
upon the completion and return of the evaluation tool. Once you
return the evaluation tool, there is no way to withdraw your
responses, as there are no identifying markers included on the
tool. Returned evaluation tools will be stored in my home for a
period of six years and then destroyed. There are no direct
benefits to you as a content expert participant. A copy of the
results including the findings of the six evaluative items in the
content expert project evaluation tool will be mailed to you at
the conclusion of this project.
If you have any questions regarding my project or the
evaluation process, please contact me via email at nixxxkk. Any
specific questions may be directed to _____, my Project Chair,
at (716) ____ or via email at____. Thank you for your
assistance and participation as a content expert. I look forward
to receiving your evaluation of my project.

Best Regards,
Appendix C
Content Expert Project Evaluation Tool

Instructions:
The purpose of this tool is to provide you with a guideline for
evaluating the clarity, readability, applicability, quality,
organization, and relevance to current evidence-based practice
of the proposed resource guide. The purpose of the project is to
develop a resource guide to provide nurses information on
discharge planning in the hospital setting. Using the four point
Likert Scale, please circle one choice that best reflects your
opinion. Space is provided after each of the six evaluative items
for further feedback and direction regarding the resource guide.
To maintain your confidentiality, please do not make any
identifying marks on the evaluation tool.
1. Clarity
The information presented in the resource guide is clearly
understood and easy to follow.

Strongly disagree
Disagree
Agree
Strongly agree
1
2
3
4
Comments and Suggestions:
2. Readability
The information in the resource guide is presented at an
appropriate and comprehensive level of reading for nurses in the
hospital setting.
Strongly disagree
Disagree
Agree
Strongly agree
1
2
3
4
3. Applicability
The information presented in the resource guid
e is relevant and fits the project purpose.
Strongly disagree
Disagree

Agree
Strongly agree
1
2
3
4
4. Quality
The resource guide is well designed and professionally
presented.
Strongly disagree
Disagree
Agree
Strongly agree
1
2
3
4
5. Organization
The resource guide is logical in order and well organized.
Strongly disagree
Disagree
Agree
Strongly agree
1
2
3

4
6. Evidence-Based Clinical Relevance
The resource guide addresses a current and clinically relevant
problem in nursing and patient care practice and utilizes current
clinical evidence.
Strongly disagree
Disagree
Agree
Strongly agree
1
2
3
4
Thank you for taking time to evaluate the resource guide. Your
feedback is deeply appreciated and will strengthen the
development of the resource guide for nurses in the hospital
setting.

Appendix E
Survey Tool Results
Corporate Valuation and Stock Valuation
CHAPTER 7
© 2020 Cengage Learning. All Rights Reserved. May not be
copied, scanned, or duplicated, in whole or in part, except for
use as permitted in a license distributed with a certain product
or service or otherwise on a password-protected website for
classroom use.
Topics in Chapter
Features of common stock
Valuing common stock
Dividend growth model
Free cash flow valuation model

Market multiples
Preferred stock
classroom use.
Corporate Valuation and Stock Valuation
classroom use.
Common Stock: Owners, Directors, and Managers
Represents ownership.
Ownership implies control.
Stockholders elect directors.
Directors hire management.
Since managers are “agents” of shareholders, their goal should
be: Maximize stock price.
classroom use.
Classified Stock
Classified stock has special provisions for each class, usually
involving voting rights and dividend rights.
Usually named Class A, Class B, etc.

New shares in IPO sometimes have voting restrictions but full
dividend rights.
Founders’ shares usually have voting rights but dividend
restrictions.
Standard & Poor’s no longer allows new additions to its indices
to have classified stock.
classroom use.
Tracking Stock
The dividends of tracking stock are tied to a particular division,
rather than the company as a whole.
Investors can separately value the divisions.
Its easier to compensate division managers with the tracking
stock.
But tracking stock usually has no voting rights, and the
financial disclosure for the division is not as regulated as for
the company.
Very few companies have tracking stock.
classroom use.
Different Approaches for Valuing Common Stock
Free cash flow model
Constant growth
Nonconstant growth
Dividend growth model
Constant growth

Nonconstant growth
Using the multiples of comparable firms
classroom use.
The Free Cash Flow Valuation Model: FCF and WACC
Free cash flow (FCF) is:
The cash flow available for distribution to all of a company’s
investors.
Generated by a company’s operations.
The weighted average cost of capital (WACC) is:
The overall rate of return required by all of the company’s
investors.
classroom use.
Value of Operations (Vop)
The PV of expected future FCF, discounted at the WACC, is the
value of a company’s operations (Vop):
classroom use.

Sources of Value
Value of operations
Nonoperating assets
Short-term investments and other marketable securities
Ownership of non-controlling interest in another company
Value of nonoperating assets usually is very close to figure that
is reported on balance sheets.
classroom use.
Claims on Corporate Value
Debtholders have first claim.
Preferred stockholders have the next claim.
Any remaining value belongs to stockholders.
classroom use.
Total Corporate Value: Sources and Claims
classroom use.
Value of operations= PV of FCF discounted
at WACC

Conceptually correct, but how do you find the present value of
an infinite stream?
classroom use.
Suppose FCFs are expected to grow at a constant rate, gL,
starting at t=1, and continue forever. What happens to FCF?
What is the value of operations if FCFs grow at a constant rate?
See next slide.
classroom use.
Value of operations in terms of FCF1 and gL:
We can multiply and divide by (1+gL), for a reason that will
soon be clear, as shown on the next slide.
classroom use.

Rewritten value of operations:
We can group , as shown on the next slide.
classroom use.
Value of operations with grouped terms:
We can group the terms, as shown on the next slide.
classroom use.
Value of operations if FCF grows
at a constant rate:
What happens toif t gets large? It depends on the size of gL
relative to WACC. See next slide.
classroom use.
What happens to as t gets large?

If gL < WACC: Then < 1.
If gL ≥ WACC: Then ≥ 1.
What happens to the value of operations if gL ≥ WACC? See
next slide.
classroom use.
What happens to the value of operations
if gL ≥ WACC?
Vop = (Big) + (Bigger) + (Even Bigger) + …+ (Really big!)
= Infinity! So g can’t be greater than or equal to WACC!
classroom use.
What happens to the value of operations
if gL ≤ WACC?
Vop = (Small) + (Smaller) + (Even smaller) + …+ FCF0
(Really small!) = ?
All the terms get smaller and smaller, but what happens to the
sum? See next slide

classroom use.
What is the sum of an infinite number of factors that get smaller
at a geometric rate?
Consider this example. The first row is t. The second row is a
number that is less than 1 that is compounded to the power of t.
The third row is the cumulative sum.t1234 . . .
∞(1/2)t1/21/41/81/161/∞ ≈ 0Σ(1/2)t1/23/47/815/16≈ 1
This sum converges to 1. Similarly, converges (although not to
1). See next slide.
classroom use.
Constant Growth Formula for Value of Operations: gL begins at
Time 1
If FCF are expected to grow at a constant rate of gL from Time
1 and afterwards, and gL<WACC:
This is the PV of all FCF from Time 1 through infinity, when
discounted at WACC.
classroom use.
Constant Growth Formula for Value of Operations: gL begins at
Time 0
If FCF are expected to grow at a constant rate of gL from Time

0 and afterwards, and gL<WACC:
This is still the PV of all FCF from Time 1 through infinity,
when discounted at WACC.
classroom use.
Data for FCF Valuation
FCF0 = $24 million
WACC = 11%
FCF is expected to grow at a constant rate of gL = 5%
Short-term investments = $100 million
Debt = $200 million
Preferred stock = $50 million
Number of shares =n = 10 million
classroom use.
Find Value of Operations
classroom use.

Total Value of Company (VTotal)
classroom use.
Estimated Intrinsic Value of Equity
(VEquity)Voperations$420.00+ ST
Inv.100.00VTotal$520.00−Debt200.00− Preferred
Stk.50.00VEquity$270.00
classroom use.
Estimated Intrinsic Stock Price per Share,
(1 of 2)Voperations`$420.00+ ST
Inv.100.00VTotal$520.00−Debt200.00− Preferred
classroom use.
Expansion Plan: Nonconstant Growth
Finance expansion financed by owners.

Projected free cash flows (FCF):
Year 1 FCF = −$10 million.
Year 2 FCF = $20 million.
Year 3 FCF = $35 million
FCF grows at constant rate of 5% after year 3.
No change in WACC, marketable securities, debt, preferred
stock, or number of shares of stock.
classroom use.
Estimating the Value of Operations
Free cash flows are forecast for three years in this example, so
the forecast horizon is three years.
Growth in free cash flows is not constant during the forecast, so
we can’t use the constant growth formula to find the value of
operations at time 0.
classroom use.
Time Line of FCFYear012345…
tFCF−$10$20$35FCF3(1+gL)FCF4(1+gL)FCFt(1+gL)
Free cash flows are forecast for three years in this example, so
the forecast horizon is three years.
Growth in free cash flows is not constant during the forecast, so
we can’t use the constant growth formula to find the value of
operations at time 0.

classroom use.
Horizon ValueYear012345…
tFCFFCF3(1+gL)FCF4(1+gL)FCFt(1+gL)HV3← ↵ ← ↵ ← ↵
Horizon value is also called terminal value, or continui ng value.
classroom use.
Horizon Value Application
(FCF3 = $35, WACC = 11%, gL = 5%)
This is the value of FCF from Year 4 and beyond discounted
back to Year 3.
classroom use.
Value of Operations at t=0: PV of FCF1 through FCF3 plus PV
of HV3Year012345… tFCFFCF1FCF2FCF3PV of FCF in
explicit forecast← ↵ ← ↵ ←
↵ FCF3(1+gL)FCF4(1+gL)FCFt(1+gL)+HV3← ↵ ← ↵ ← ↵ PV
of HV← ↵ ← ↵ ← ↵ = Value of operations Time 0
PV of HV is the PV of FCF beyond the explicit forecast. So PV

of HV plus PV of FCF in explicit forecast is the PV of all future
FCFs.
classroom use.
Application: Current Value of Operations (Nonconstant g in
FCF until after Year 3; gL = 5%; WACC = 11%)
classroom use.
Estimated Intrinsic Stock Price per Share,
(2 of 2) Voperations$480.67 + ST Inv. 100.00
VTotal$580.67 −Debt200.00− Preferred Stk.
50.00VEquity$330.67 ÷ n 10 $33.07
classroom use.
How much of the value of operations is based on cash flows
from Year 4 and beyond?
The horizon value is the value of all FCF from Year 4 and
beyond, discounted back to Year 3.
The present value of HV3 is the present value of all FCF from
Year 4 and beyond.

The PV of HV3 is the percent of total value due to long-term
cash flows.
classroom use.
Value of Operations and Present Value of Horizon Value
Value of operations: Vop = $480.67
Horizon value: HV3 = $612.5
PV of HV3 = $612.5/(1 + 0.11)3
= $447.855
classroom use.
Percent of Value Due to Long-Term Cash Flows
In this example, 93% of value is due to cash flows 4 or more
years into the future.
For the average company, this percentage is around 80%.
classroom use.
Long-term versus Short-term Focus
Why focus on quarterly earnings if most value is from longer-

term cash flows?
Changes in quarterly earnings can signal changes future in cash
flows. This would affect the current stock price.
Managers often have bonuses tied to quarterly earnings, so they
have incentive to manage earnings.
classroom use.
Forecasting Free Cash Flows: A Simple Approach
Forecast sales to grow at chosen growth rates.
Forecast net operating profit after taxes (NOPAT) and total net
operating capital (OpCap) as a percent of sales.
classroom use.
Current Situation (in millions)
Most recent data:
Sales of $2,000
Total net operating capital, OpCap = $1,120
Operating profitability ratio
OP = NOPAT/Sales = 4.5%
Capital requirement ratio
CR = OpCap/Sales = 56%.
The target weighted average cost of capital (WACC) is 9%.

classroom use.
Initial Operating Assumptions for the No Change Scenario
Operating ratios remain unchanged from values in most recent
year.
Sales will grow by 10%, 8%, 5%, and 5% for the next four
years.
The long-term growth rate in sales is 5%.
The target weighted average cost of capital (WACC) is 9%.
classroom use.
AssumptionsActualForecastInputs01234WACC9.0%Sales$2,000
OpCap$1,120Sales growth
rate10%8%5%5%NOPAT/Sales4.5%4.5%4.5%4.5%4.5%OpCAP
/Sales56.0%56.0%56.0%56.0%56.0%
classroom use.
Examples of Forecasting Items
Sales1 = $2,000(1+0.10) = $2,200
NOPAT1 = $2,200(0.045) = $99
OpCap1 = $2,200(0.56) = $1,232
FCFt = NOPATt − (OpCapt − OpCapt-1)
ROICt = NOPATt/OpCapt

classroom use.
Forecasted FCF: No changes in operating ratiosScenario:
No
ChangeActualForecast01234Sales$2,000$2,200$2,376$2,495$2,
620NOPAT$99$107$112$117.879OpCap$1,120$1,232$1,331$1,
397.088$1,466.942FCF −$13$8.36$45.738$48.025Growth in
FCF-164%447.1%5.0%ROIC8.0%8.0%8.0%8.0%8.0%
FCF is negative in Year 1.
ROIC of 8% is less than WACC of 9%--not good!
Note: There is no rounding in intermediate calculations.
classroom use.
Estimated Intrinsic Value (1 of 2)
classroom use.
Estimated Intrinsic Value (2 of 2)Scenario: No ChangeHorizon
Value:HV4 =$1,260.65Value of Operations:Present value of
HV$893.08+ Present value of FCF$64.45Value of operations
≈$958

classroom use.
The Value of Operations versus the Total Net Operating Capital
The ROIC (8%) is too low compared to the WACC (9%).
The capital is not earning enough to meet investors’ required
return, so:
Horizon value ($958) is less than the total net operating capital
at the horizon ($1,467).
Current value of operations ($958) is less than the current total
net operating capital ($1,120).
ROIC must be greater than WACC/(1+gL) for horizon value to
be greater than the total net operating capital at the horizon.
classroom use.
Value Drivers
The ROIC (8%) is too low compared to the WACC (9%).
The capital is not earning enough to meet investors’ required
return, so:
Horizon value ($958) is less than the total net operating capital
at the horizon ($1,467).
Current value of operations ($958) is less than the current total
net operating capital ($1,120).
ROIC must be greater than WACC/(1+gL) for horizon value to
be greater than the total net operating capital at the hori zon.

classroom use.
Impact of Higher Growth RatesNo ChangeImprove
Growthg0,110%11%g1,28%9%g2,35%6%g3,45%6%gL5%6%OP
4.5%4.5%CR56.0%56.0%ROIC8.0%8.0%Vop,0$958$933WACC
9.00%9.00%
Higher growth causes Vop,0 to fall.
ROIC must be greater than WACC/(1+WACC) for growth to add
value.
WACC/(1+WACC) = 8.26%
classroom use.
Impact of Higher Operating ProfitabilityNo ChangeImprove
OPg0,110%10%g1,28%8%g2,35%5%g3,45%5%gL5%5%OP4.5
%5.5%CR56.0%56.0%ROIC8.0%9.8%Vop,0$958$1,523WACC9
.00%9.00%
Higher operating profitability increases the ROIC.
ROIC of 9.8% > 8.26%
The higher ROIC causes a big increase in Vop,0.
classroom use.
Impact of Lower Capital RequirementsNo ChangeImprove
CRg0,110%10%g1,28%8%g2,35%5%g3,45%5%gL5%5%OP4.5
%4.5%CR56.0%51.0%ROIC8.0%8.8%Vop,0$958$1,191WACC9

.00%9.00%
Lower capital requirements increases the ROIC.
ROIC of 8.8% > 8.26%
The higher ROIC causes an increase in Vop,0.
classroom use.
Impact of Simultaneous Improvements in OP and CRNo
ChangeImprove OP and
CRg0,110%10%g1,28%8%g2,35%5%g3,45%5%gL5%5%OP4.5
%5.5%CR56.0%51.0%ROIC8.0%10.8%Vop,0$958$ 1,756WACC
9.00%9.00%
The ROIC is much higher due to the improvements in
operations.
classroom use.
Impact of Simultaneous Improvements in Growth, OP, and
CRNo ChangeImprove
Allg0,110%11%g1,28%9%g2,35%6%g3,45%6%gL5%6%OP4.5
%5.5%CR56.0%51.0%ROIC8.0%10.8%Vop,0$958$2,008WACC
9.00%9.00%
operations.
With a higher ROIC, growth adds substantial value.

classroom use.
Summary: Value of operations for previous combinations of
ROIC and
gLROICROICROICROICROIC8.0%8.8%9.8%10.8%gL5%$958$
1,191$1,523$1,756gL6%$933$1,247$1,694$2,008
operations.
With a higher ROIC, growth adds substantial value.
classroom use.
Are volatile stock prices consistent with rational pricing?
The previous slide shows that small changes in ROIC and
growth cause large changes in value.
Similarly, small changes in the cost of capital (WACC), perhaps
due to changes in risk or interest rates, cause large changes in
value.
As new information arrives, investors continually update their
estimates of operating profitability, capital requirements,
growth, risk, and interest rates.
If stock prices aren’t volatile, then this means there isn’t a good
flow of information.
classroom use.

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