EDUCATIONAL TRAINING PROGRAM FOR NURSES IN AN OUTPATIENT SETTI

EDUCATIONAL TRAINING PROGRAM FOR NURSES IN AN
OUTPATIENT SETTING TO PROVIDE EDUCATION
REGARDING THE IMPORTANCE OF A HEALTHY DIET
FOR PATIENTS WITH OBESITY
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
Family Nurse Practitioner
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 student name.
20
PROJECT APPROVAL
Project Committee Chairperson
Name:
__
____________________________________________________
Signature:

___________________________________________________
Discipline:
___________________________________________________
Project Defended
On
[Month Day, Year]
Abstract
[The abstract is presented before Chapter I. It consi sts of 120
word (maximum) succinct summary of the entire project and
highlights the details of the identified problem, the project
purpose, the theoretical framework(s), and evaluative measures.
The abstract heading is not bolded or indented 5 to 7 spaces.]
Acknowledgment
[Inclusion of an acknowledgment page is optional. The student
should seek guidance from the project director on whether to

include the page in the final project manuscript. If it is
included, it is numbered as page Roman numeral v, each
paragraph is indented five spaces (1/2"), and the text is double -
spaced. This page is placed just after the Abstract and Table of
Contents.]
Table of Contents
Chapter
I. PROJECT INTRODUCTION
..................................................................... 8
Statement of Purpose
................................................................................... 9
Theoretical Framework
............................................................................... 9
Initial Review of the Literature
...................................................................13
Significance and Justification
.....................................................................19
Project Objectives
.......................................................................................19
Definition of Terms

...................................................................................
Project Limitations
....................................................................................
Project Development Plan
.........................................................................
Plan for Protection of Human Subjects
.....................................................
Plan for Project
Evaluation........................................................................
Summary
...............................................................................................
....
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
...............................................................................................
.. 21
Appendices
...............................................................................................
.
List of Appendices
Appendix
A D’Youville Patricia H. Garman School of Nursing Full
Approval Letter
…………………….…. 60
B Letter of Intent
...............................................................................................
.. 62
C Evaluation Tool
...............................................................................................
64
D Product
...............................................................................................
............. 66
E Survey tool results in
graph……………………………………………….

Chapter I
The age of fast food and instant gratification brought about by
the growth of technology has affected the general population in
many ways. In America, obesity is becoming problematic, with
a prevalence estimate of 41% leading to risk in the severity of
diseases (Kalligeros et al., 2020). As a result, there is a need for
nursing practice to take accountability in developing a
relationship with collaborative patient care. Obesity can be a
lifestyle disease. Therefore, all stakeholder participation must
be considered a need to look at the four-metaparadigm
perspectives in caregiving using a foundational basis in a
theoretical framework. First, a nurse needs expertise in
addressing health issues, especially those reversible through
natural means, for example, obesity. Obesity is reversible
through natural means, including dietary modification and
practicing fasting.
The factors that make a successful program include proper
planning. Proper planning allows for allocating adequate time
and resources toward the project, resulting in the successful
implementation of the program (Shi, 2017:p.80). Another factor
is incorporating experienced project managers with knowledge
about the program. For example, specialists such as nutritionists
and experts in physical activity and breastfeeding are essential
when developing a program to improve nutrition in children and
adults and minimize obesity. Finally, it is essential to practice
monitoring and control for a program to succeed. Regular
evaluation of the progress and the program results allows for
modification and alignment in case of an error or a potential
error—effective communication results in a program's success
(Alulis & Grabowski, 2017:p.630).

The programs in the articles are good ways to effect cultural
change. Education plays a significant role in making people
adopt healthy habits. Education is well achievable after
evaluating the clients through wellness programs and other
community programs that involve health checkups and
screening. However, personal barriers such as individual change
resistance may negatively impact the success of the social
change (Allan, 2020:p.350). Some people are susceptible to
changes they perceive as threats to their social environment,
including the workplace. Individuals may develop resistance to
change when they feel uncertain about the intervention, when
the change comes as a surprise without the time to prepare
mentally, and the questions about the competency of the
intervention concerning the new environment—the resistance
results in difficulty in implementing the intervention to achieve
social change. This study will assess interpersonal relations in
nursing theory to draw mechanisms for developing effective
strategies for an educational plan for nurses taking care of
patients with obesity in an outpatient department. The program
will major on how nurses can effectively pass educative
information to the clients on dietary intervention as a critical
mechanism for reversing obesity. The idea considers all the
possible challenges that nurse educators may experience while
trying to enhance social change among patients.
Statement of Purpose
This project aims to develop an educational training program
for nurses in an outpatient setting to provide education
regarding the importance of a healthy diet for patients with
obesity.
Theoretical Framework
Hildegard Peplau's (2004)
Interpersonal Relations in Nursing Theory is utilized as
the theoretical framework for developing this project. A brief
overview of the theory is presented as well as a discussion

regarding how the theory was utilized to guide the project's
development. In addition, Peplau’s (2004) theoretical
definitions for nursing’s four metaparadigm sequential
interpersonal relationships and concepts and the Project
Author's operational definitions for nursing's four metaparadigm
concepts will be presented. These metaparadigm concepts are
foundational elements as orientation, identification,
exploitation, and resolution defined within nurse, health,
patient, and environments aspects of nursing healthcare
provision. As such, the theory emphasizes the importance of
crosscutting issues and their effect on nursing care and patient
wellness, such as nursing education on dietary interventions for
patients with obesity, as in this study.
It thus facilitates better planning to understand the
complexities of issues underlying the patient's conditions,
which would hinder getting well. In recognition of this, this
paper aims to bring to attention the definition of the
metaparadigm concept of patient care within this theory by
looking at its significance and interpersonal relationship as
contextualization in patient care. At the same time, the paper
will look at its actual application as employed in modern
nursing care as a mainstream cultural competency component.
Finally, the deliberate look of this theory within this aspect will
facilitate a conclusion on the modern-day emphasis and
necessitated patient-centered model of care. Significance of
Interpersonal Relations Nursing Theory
As a mother of nursing psychiatry, Peplau (2004) describes
interpersonal relations as a conditional aspect that includes first
the interaction of the nurse and patient. She points out that this
is attained when understanding each patient's condition is an
experience that allows for improving nursing care (Peplau,
2004, p. 2). Therefore, the focus in the definition of the theory
begins with grasping the nurse and patient metaparadigm
concepts as the interaction between patient and nurse makes the

relationship personal. Similarly, considerable insights thus
point out that the patient care process is personalized in a way
that responsibility is both technical and emotional. Peplau
(2004) explains that effective patient outcome delivery comes
from trust in diagnostics and thus acceptance of health as an
essential metaparadigm aspect. The theory focuses on
developing the relationship between a nurse and a patient to
emphasize trust and collaboration. This theorist is a perfect fit
for the proposed educational training program for nurses in an
outpatient setting to provide education regarding the importance
of a healthy diet for patients with obesity. The relationship
between the outpatient and the nurse must be founded on trust
so that information can be shared comfortably and with trusted
support from nurses. A support system must be developed
because obesity and the issues surrounding obesity can often
bleed into self-esteem and mental health. This theorist ideology
will assist in identifying and orienting nurses to the causes of
obesity, introducing a perfectly balanced diet with regular
exercise, and finally producing solutions for diabetic
prevention, a foundation that this theoretical framework
supports.Metaparadigm Concepts in Interpersonal Relations
Nursing Theory
Thus, nursing can be defined based on culture and concrete
work (Peplau, 2004; p.5). Thus, it promotes health through
appropriate methods and illness prevention by recognizing
triggers for all patients. Therefore, the nurse can only facilitate
treatment and not make a diagnosis; hence, the critical aspect is
ensuring that the environment is conducive and that
communication in the relationship with patients is constant.
This means the nurse favors patients' understanding of their
issues by explaining the problem and the treatment plan. This
includes a preventive measure to ensure informed decision-
making is enhanced and thus a partnership that, in essence, is
therapeutic.
Communicative action in the digital age between nurse and

patient is bold navigation of interpersonal relationships. On the
other hand, the increase in maintenance tendency takes a newer
approach, as information overload can be present due to media.
This could be advantageous for outpatient care, but the opposite
is true. As such, following Peplau’s underpinning of patient
care, nursing is the implementation of need-based healthcare
delivery through the respectable promotion of perception and
prevention of escalation of illness (Peplau, 2004, p. 9).
Therefore, it can be said that the operational definition of
nursing is ensuring that patient needs are met adequately and
suitably hence unique to the patient. With that, a different
relationship develops between nurse and patient.
In recognition, a person is operationally defined as an entity
with individual preconceptions and mutual understanding of the
nature of a medical issue and collaborates towards a productive
solution. Therefore, this contextualizes the environment as
conditions that allow for human processes that facilitate
tendencies supportive of positive development to attain health
(Peplau, 2004, p. 12). By this definition, health can
operationally be defined as a symbolic future positive goal that
is attained after effective healthcare hence instrumental for the
person moving in the forward direction of wellbeing (Peplau,
2004, p. 13).
Operations Definition of Nursing Metaparadigm Under
Interpersonal Relations Nursing Theory
For this project, the operational definition of the nurse is a
supporter who ensures that patient needs are unique and met
adequately and suitably to their circumstance. This recognizes
that a different relationship develops between nurse and patient
from one. In the same stance, a person is operationally defined
as an entity with individual preconceptions and a mutual
understanding of the nature of a medical issue. Within this
understanding, they can collaborate with informed decision-
making toward a productive solution. It thus supports the
operational definition of the environment as contextualized

conditions that allow for human processes that facilitate
tendencies supportive of positive development to attain health
(Peplau, 2004, p. 12). By this definition, there is support for
operationally defined health as a symbolic future positive goal
that is attained after effective healthcare hence instrumental for
the person moving in the forward direction of wellbeing
(Peplau, 2004, p. 13).Initial Review of the Literature
The review of the literature will be conducted to explore studies
that are associated with nursing education for obesity and
healthy diet. Using the following words both singularly and in
multiple combinations: nursing training, obesity, outpatient
care, nursing psychiatry, overweight, diet, obesity facts,
obesity prevention, body weight, and care management
planning. Databases searched, limited to the years 2017 and
2022, will include AMED, Alt Health Watch, CINAHL Plus
with Full Text, EBSCO, Medical Journal sites for nursing care,
nursing training, PubMed, Scopus, Science Direct, Directory of
Open Access Journals, Google Scholar, JSTOR 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.
Dynamics of Outpatient Care
According to Balani et al., (2019) The epidemic of obesity is a
significant health crisis that continue to increase globally, it is
reported that in the United States, more than two thirds of
adults are considered either overweight or obese. A lifestyle
disease is critical to the discussion on nursing care for
outpatient obesity. As such, care focuses on management and
fostering better and healthy weight maintenance (Kalligeros et
al., 2020). Thus, it does not necessarily focus on age but
understands that eagerness is also a risk factor for comorbidities
associated with being overweight. Furthermore, Kalligeros et al.

(2020) study points out that the exploration of the association
between obesity and chronic diseases is something that should
be understood. This is because there is a direct relation between
the severity of the outcomes seen in intensive care units and
admission rates. For example, research that analyzes a
retrospective cohort with 103 patients found out that of the
patients admitted to the hospital history of heart disease is a
direct result of obesity. Therefore, a recommendation is that
vigilance should be given to treating patients with obesity
starting from the outpatient setting, alluding to necessitated
prevention of escalation when faced with other conditions
(Kalligeros et al., 2020).Role of Nursing
The role of nursing is to provide integrated care and enhance
patient comfort by providing interventions to alleviate
symptoms of obesity. Findings from Rezaei et al. (2022) study
point out that high morbidity rates are caused by poor health
maintenance, which aligns with the results in Smith et al.'s
(2020) and Sutaria et al. (2020) studies. Furthermore, Gadde et
al. (2018) study findings indicate a significant reduction in
morbidity and mortality rates among patients in weight
maintenance trials. The high number of obesity cases creates a
risk factor in the population; this points to the need to
emphasize the training for this. Recognizing physician effort in
collaboration with outpatient by sensitization on environmental
awareness is essential (Walia et al., 2022). This includes
considering that proper evaluation starts by recognizing the
appropriateness of the environment for supporting weight
management. Achieving and maintaining weight loss or gain
requires physician-patient collaboration in a way that can be
facilitated by nurses providing pertinent information. Again,
support and motivation are also determined by letting a
carefully defined plan be identified with the patient to
understand the expected health outcomes. This is the nurse's
work as it allows for the recognition of a strategy of control for
each patient (Stonerock & Blumenthal, 2017:p.1457).

According to Rezaei et al. (2022), the combination of aspects
such as cost of health, care expenditures, and hospitalization
risks are some of the reasons that can be used in motivating
outpatients to adhere to their plan of losing weight. This study
aligns with the findings of Piché et al. (2020) study findings.
The findings indicate that advanced heart diseases are often
caused by obesity and lack of maintenance, and the determinant
of failure lies in the early handling of the issue. Therefore,
health literacy is an integral part of the nursing fraternity to
impart to the patients as it allows for the opportunity to
understand the implication of obesity in the long run.
Consequently, the narrative is applicable because by the time
medication is involved, the progression will be higher risk
associated and thus significant mortality risk, however, creating
a provider-patient relationship with healthy diet, diabetic and
obesity teaching without having a judgmental response,
whereby both parties agrees on goals, share a vision of
improvement in general metabolic health status, the patient and
provider will been able to create a personalized and
participatory lifestyle changes plan as described by Foley et al.
(2019) study. Furthermore, Alexander et al. (2021) study
findings indicate that health literacy as part of outpatient
training will provide the necessary support for proper weight
loss and maintain it while allowing room for recognition of
mental health too. This caters to the grasping of the
incorporation of strategies that align outcomes centered on the
totality of patient care within the six sigma of quality
improvement in healthcare delivery.
Alexander et al. (2021) research focuses on promoting
healthcare delivery as a focal point in preventive care and is
supported by Levine et al. (2019), which look at a similar issue
but with a different approach. Levine et al. (2019) surveyed to
find out why the use of preventive healthcare is still low in the
modern healthcare system. The findings from the survey linked
modernization and the advancement in technology as one the
contributors to the limited use of preventive medicine.

Nevertheless, Harris et al. (2017) points out how using
preventive healthcare would enhance the efficiency of care and
result in better outcomes. Therefore, Alexander et al. (2021),
Levine et al. (2019), and Harris et al. (2017) studies
collectively look at transitioning patients from outpatient to
inpatient and provide insight on what to avoid and what is
necessary to promote better care. From the start, the studies
allow room for relativity in practices that promote and optimize
safety, and within those points to the relevance of individual
patient circumstances. While the paper gives valuable
information on the standard procedure, it contributes to the
general discussion on the improvement of health by nurses. It
thus applies that, for all patients, recognition of the value in
situation background assessment facilitates the improvement of
health outcomes. The improvement starts with a reduction in
risks hence understanding beneficial outcomes accurately firs t
(Alexander et al., 2021).Recognition of Potential Barriers
There is also a need to recognize the impact of cultural
competency in nursing care (Chae & Park, 2019). With
outpatients, there is a risk of exposure to external biases and
pressure that may result in declining health whenever they leave
a session. Therefore, value must be provided in educating the
patient on the potential risks they face within their environment.
This can only be achieved through collaboration which aligns
with the results of Seger's (2019) and Ogbolu et al. (2018)
studies. Furthermore, it is essential for the perspective of the
community and support system for the patient to be observed by
the patient (Bloor & McIntosh, 2019). Therefore, sharing with
the nurse is a natural step of goal setting that allows an
informed understanding of the underlying implication of the
stereotypes and norms of expectation (Halvorson et al., 2019).
This will help focus on reducing the risk of "temptation" of
hindrances to improving patient health in a way that respects
them and their communities. Similarly, (Balani, et al., 2019)
study examined factors affecting healthy weight in the

community, the study explained that obesity is not basically a
lifestyle crisis, but rather is a complicated, chronic disease
affecting areas of behavioral, psychosocial, biological, and
environmental factors. For this reason, there is a need for
collaborative and comprehensive approach for obesity
management. Therefore, foundational planning is essential for
the nurse and the patient to recognize early on.
According to Hee Soon, et al. (2019) opted to conduct a study
on this subject .focusing on the younger populations, One thing
that tends to be overlooked is the fact that children tend to learn
from what they see happening in their surroundings, thus, even
if a child is prone to eating healthy when they are in their
respective homes, they are also prone to be influenced by what
they see in schools, or other surroundings. This research study
aimed at answering the question “What are the barriers at home
and school to healthy eating?” It also aimed at answering this
through the perspectives of parents and children who had or
were suffering from obesity, therefore, parents, teachers, and
community healthcare providers should alleviate the issues of
obesity through adequate healthy diet teaching and
implementations.
It is imperative when it comes to the management of unvoiced
expectations of a patient in a way that recognizes their efforts
and input towards change. According to Ma et al. (2019) study
findings, obesity management requires self-discipline at a
higher level than average and recognizing a gradual result,
supported by Reas's (2017) study. These studies describe how
lack of self-discipline results in binge eating disorder; at the
same time, public and healthcare professionals’ knowledge, and
attitudes toward the relationship between self-awareness results
in binge eating disorder and, consequently, weight gain
(obesity). The fact that it cannot be cured by medication and
results are not immediate is a cause of concern that both nurse
and patient should understand (Boersema et al., 2021:p.11). It
requires patience and a lens where small milestones can only
weigh competent management. Furthermore, obesity

practitioners must have complete comprehension and apply
evidence-based knowledge while administering care for patients
with obesity (Srivastava et al., 2019:p.196).
When management optimization is needed in the treatment
strategy for a patient with obesity, especially outpatients, there
is a need for longitudinal consideration of the
comprehensiveness of management aspects. According to Seger
(2019), a complication of obesity as a chronic illness is as
sophisticated as any other issue, which aligns with Godfrey et
al. (2017) study. Godfrey et al. (2017) describe the
complications primarily associated with maternal obesity,
including coronary artery disease, obesity in the offspring,
asthma, and allergies. In addition, Schetz et al. (2019) describe
obesity as one of the current health concerns affecting a large
proportion of the world's population. As such, an intensity level
should be employed with preventive controls in line with the
responsibility set. This allows for desired treatment to be the
main goal rather than the desired end product, such as specific
weight. It removes the tension without negating the implication
of the process and thus optimizes input by the small measures
that can be seen regularly. Therefore, a pathophysiological
approach is necessary for an all-hands-on methodology hence
simplicity that is specific to the patient in question rather than a
generalization as in Block et al. (2020) study findings. Nurses'
knowledge of management of obesity
Inadequacy of skills and knowledge among healthcare
professionals is one of the significant challenges facing the
fight against metabolic conditions such as obesity. Bucher Della
Torre et al. (2018) describe one of the challenges in one of the
university hospitals as the presentation of poor knowledge,
skills, and attitude about obesity among nurses and physicians,
which aligns with the findings of Turner et al.'s (2018) study.
Turner et al.'s study revealed inadequate knowledge concerning
managing obesity effectively. The results imply that provider
perception of optimal healthcare services for obesity is at odds

with research-based guidelines. Health care practitioners must
be aware of the best ways to use pharmacotherapy and
behavioral counseling, such as adopting a healthy diet; these
interventions are widely applied in improving the health of
obese patients (Turner et al., 2018:p.667).
Reinforcing Positive environment in Nurse-Patient Relationship
When looking at the studies, it is evident that nurse and patient
relationships are integral to both the definition of health and the
understanding of treatment planning. These are essential to the
pathways to positive outcome expectation hence accurate to the
operational definitions. Given that outpatient care for obesity is
almost therapeutic, there is a sense of delivery requiring that
verbal and non-verbal communication are read. As such, the
nurse must have the core conditioning of genuine concerns,
which sometimes could be perceived as going above and beyond
the baseline required (Okdie & Ewoldsen, 2018). The
relationship between the two is skill-based, examining the level
of trust in both directions with absolute truths. The points of
conflicts should thus be handled with care and isolated from the
goals by accepting attitudes as progression hence the removal of
fear (Walia et al., 2022). This also removes the anxiety of either
side as the nurse can trust that discipline will be employed
within the period they have not met. Similarly, the patient will
trust that information will not be withheld, anger will not be
enforced, and the environment of care will be positively
reinforced with empathy rather than pity.
Findings from the initial literature review revealed that a lack
of knowledge exists in nursing and patient care practice
regarding obesity management. In their study, Bucher Della
Torre et al. (2018) revealed a significant inadequacy of
knowledge and skill among nurses and physicians working in a
university hospital concerning the management of obesity
(Bucher Della Torre et al., 2018: p.126). This gap exists, yet
healthcare professionals ought to be at the forefront in

executing various interventions in managing obesity. It is an
implication that patients suffering from obesity and related
complications will find it challenging to get adequate and
effective nursing education concerning diet to manage and treat
their condition. Similarly, there is inconsistency in provider
understanding of appropriate clinical care for obesity. The study
recommends that there is a need for healthcare professionals to
develop an understanding of how to effectively leverage health
interventions to promote outcomes for patients with obesity.
This article is a good choice for supporting the proposed project
because it points out the limitations of proper management of
obesity, one of which is the low knowledge level among health
professionals and the need to address them towards achieving
the goal of healthcare. Therefore, this study must enable nurses
to have a training program where they will get more knowledge
and skills concerning the management of obesity through
dietary interventions. It will optimize patient outcomes through
effective nursing education.
Project Objectives
The objectives of this project are to:
1. Conduct an extensive review of the literature exploring
healthy diet for patients with obesity using the following
keywords both singularly and in multiple combinations: nursing
training, obesity, obesity prevention, outpatient care,
overweight, diet and healthy diet. Databases searched, limited
to the years 2017 to 2022, will include, AMED, Alt Health
Watch, CINAHL Plus with Full Text, EBSCO, Medical Journal
sites for nursing care, nursing training, PubMed, Scopus,
Science Direct, Directory of Open Access Journals, Google
Scholar, JSTOR and the D'Youville library to loan articles
through interlibrary loan;

2. Develop a (resource guide; brochure, PowerPoint, Video,
etc.); and
3. Have a panel of five content experts with extensive
knowledge and expertise in healthy diet for patients with
obesity evaluate and critique the project for clarity, readability,
applicability, quality, organization, and evidence-based clinical
relevance.
THIS WEEK -
PLS FOLLOW THE INRUSTION THOROUHLY
7. Instructions for the Definition of Terms section
The Definition of Terms section follows the Project Objectives
section. In this section, the Project Author presents additional
theoretical and operational definitions (other than nursing’s four
metaparadigm concepts) applicable to the project purpose as
appropriate. Concepts found in the project Statement of Purpose
should be defined. Conceptual/theoretical definitions should be
discipline specific and need to reflect the theoretical framework
and purpose of the project. Theoretical definitions state the
meaning of a concept as it is defined or described by the
theorist/theory. Theoretical definitions need to be obtained and
cited from the primary source – the most current version or text
of the theory. Theoretical definitions can also come from
professional organizations and associations. Dictionary and
Wikipedia definitions are not acceptable sources for the
definition of terms. All theoretical definitions are cited in APA
format from the source they are retrieved from. An operational
definition is the Project Author’s definition of a theoretical
concept as it specifically reflects the project purpose. At times,
theoretical and operational definitions may be defined the same.
If a student wishes to operationally define a term as it is
theoretically defined, the student needs to cite the source the
definition was retrieved from. The Definition of Terms section
should be presented as follows:

Definition of Terms
The following concepts are defined both theoretically and
operationally for the purpose of this project:
Health Promotion –(Sample-put our topic) and our references
Theoretical Definition: Behavior motivated by the desire to
increase well-being and actualize human health potential. It is
an approach to wellness (Pender et al., 2011, p. 45).
Operational Definition: Behaviors that promote HGH treatment
delivery and adherence resulting in improved health, treatment
outcomes, and better quality of life for adolescents diagnosed
with HGH deficiency.
Theoretical and Operational Definition:
8. Instructions for the Limitations section
This section follows the Definition of Terms section. Every
research study or project has limitations
(problems/issues/concerns) that the Project Author experienced
while conducting a study or developing a project that may be
addressed or remedied in future studies/projects…there is no
perfect study or project! The Limitations section informs the
reader of the study or project’s problems/issues/concerns that
the Project Author experienced. The Limitations section begins
as follows and may include but are not limited to the following:
Limitations
The Project Author recognizes the following project limitations:
1. The implementation of the (-brochure, PowerPoint, Video,
etc.); is not within the context of this project;
2. The (product) is developed in the English language only and
may benefit a more culturally diverse population if written in

additional languages
9. Instructions for the Project Development Plan section
The Project Development Plan section follows the Limitations
section. In this section, the student describes how they will
develop their project. This section should be presented as
follows:
A detailed topical outline of the (product) 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 (product). After permission is granted from
the D’Youville Patricia H.
Garman School of Nursing, graduate faculty designee
(Appendix A),
(5) professionals with knowledge and expertise in (the project
area of focus/field) will be asked if they are interested in
voluntarily participating as an expert content reviewer for the
(product).
The content expert panel will consist of one
, one
, one
, one
, and one
. 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
(product) (Appendix D), and a
WE STOP HERE FOR NOW….
References
Alexander, C. C., Tschannen, D., Hays, D., Clouse, M.,
Zellefrow, C., Amer, K. S., ... & Milner, K. A. (2022). An
integrative review of the barriers and facilitators to nursing
engagement in quality improvement in the clinical practice
setting.
Journal of Nursing Care Quality,
37(1), 94-100.
Alexander, C., Rovinski-Wagner, C., Wagner, S., & Oliver, B.
J. (2021). Building a Reliable Health Care System: A Lean Six
Sigma Quality Improvement Initiative on Patient Handoff.
Journal of Nursing Care Quality,
36(3), 195-201.
Allan, J. (2020). Theorizing new developments in critical social
work. In
Critical social work (pp. 30–44). Routledge.
Alulis, S., & Grabowski, D. (2017). Theoretical frameworks
informing the family-based child and adolescent obesity
interventions: A qualitative meta-synthesis.
Obesity Research & Clinical Practice,
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1
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 sample 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.
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
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.

EDUCATIONAL TRAINING PROGRAM FOR NURSES IN AN OUTPATIENT SETTI

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