The Early Novel in the Western World  Listen to the Audio Early Western literature, especially the picaresque tale, flourished in Spain. These often quite long stories narrated the adventures of a soldier of fortune living the carefree life on the open road and getting involved in all sorts of intrigues and love affairs. The Spanish also had tales similar to the King Arthur legends, dealing with the adventures on the road of brave and dashing knights who were superheroes; tremendous in battle and noble and chivalrous toward their true loves. The first known major novelist of the Western world was Miguel de Cervantes Saavedra (1547–1616), whose life span closely parallels Shakespeare’s. His Don Quixote (written between 1612 and 1615) remains one of the most popular and beloved of all novels. The central character is an old man who has read so many stories of brave knights that he has gone mad and believes himself to be one of them. Riding a broken-down old horse named Rocinante and attended by his faithful squire Sancho Panza, he goes off in search of glorious adventure (Figure 4.1). Intended originally as a satire on the ridiculous excesses of the wandering knight story, Don Quixote became, in the opinion of many, a tragic tale of an idealist who sees the world not as it is but as it ought to be: a world in which people are driven by the noblest of motives, chivalry prevails, and love means forever. As an adventure story, Don Quixote influenced the work of many novelists who followed, setting the pattern for long, loosely structured yarns that would find a home in the magazine serials of the eighteenth and nineteenth centuries. The serial was a publishing gimmick, each episode ending with the hero or heroine in a perilous strait, and thus keeping the reader coming back to purchase more issues. The English novel had its true beginnings in the eighteenth century. The coming of the magazine fostered a passion for fiction that had potential novelists busily scribbling. But the period was also one of a passion for science and its search for truth. Those who dictated the taste of the reading public insisted that a lengthy published work, to be worth the time spent in reading it, must at least pretend to be a true story. Consequently, much fiction was passed off as biography or autobiography, and this meant that the author’s real name was often omitted. For example, Gulliver’s Travels (1726) by Jonathan Swift and Robinson Crusoe (1719) by Daniel Defoe, two enduringly popular works of fiction, pretended to be nonfictional accounts of actual adventures, and Pamela: Virtue Rewarded (1740), by Samuel Richardson was an epistolary novel, consisting solely of letters “written” by its 15-year-old heroine. American writers were slow to gain recognition and respect abroad. In the early nineteenth century, British critics were asking, “Who reads an American book or goes to see an American play?” These questions incurred the wrath of American authors, who promp.

1. The Early Novel in the Western World
Listen to the Audio
Early Western literature, especially the picaresque tale,
flourished in Spain. These often quite long stories narrated the
adventures of a soldier of fortune living the carefree life on the
open road and getting involved in all sorts of intrigues and love
affairs. The Spanish also had tales similar to the King Arthur
legends, dealing with the adventures on the road of brave and
dashing knights who were superheroes; tremendous in battle and
noble and chivalrous toward their true loves.
The first known major novelist of the Western world was
Miguel de Cervantes Saavedra (1547–1616), whose life span
closely parallels Shakespeare’s. His Don Quixote (written
between 1612 and 1615) remains one of the most popular and
beloved of all novels. The central character is an old man who
has read so many stories of brave knights that he has gone mad
and believes himself to be one of them. Riding a broken-down
old horse named Rocinante and attended by his faithful squire
Sancho Panza, he goes off in search of glorious adventure
(Figure 4.1). Intended originally as a satire on the ridiculous
excesses of the wandering knight story, Don Quixote became, in
the opinion of many, a tragic tale of an idealist who sees the
world not as it is but as it ought to be: a world in which people
are driven by the noblest of motives, chivalry prevails, and love
means forever. As an adventure story, Don Quixote influenced
the work of many novelists who followed, setting the pattern for
long, loosely structured yarns that would find a home in the
magazine serials of the eighteenth and nineteenth centuries. The
serial was a publishing gimmick, each episode ending with the
hero or heroine in a perilous strait, and thus keeping the reader
coming back to purchase more issues.
The English novel had its true beginnings in the eighteenth
century. The coming of the magazine fostered a passion for
fiction that had potential novelists busily scribbling. But the
period was also one of a passion for science and its search for

2. truth. Those who dictated the taste of the reading public insisted
that a lengthy published work, to be worth the time spent in
reading it, must at least pretend to be a true story.
Consequently, much fiction was passed off as biography or
autobiography, and this meant that the author’s real name was
often omitted. For example, Gulliver’s Travels (1726) by
Jonathan Swift and Robinson Crusoe (1719) by Daniel Defoe,
two enduringly popular works of fiction, pretended to be
nonfictional accounts of actual adventures, and Pamela: Virtue
Rewarded (1740), by Samuel Richardson was an epistolary
novel, consisting solely of letters “written” by its 15-year-old
heroine.
American writers were slow to gain recognition and respect
abroad. In the early nineteenth century, British critics were
asking, “Who reads an American book or goes to see an
American play?” These questions incurred the wrath of
American authors, who promptly responded in a variety of
ways. There was Washington Irving (1783–1859) and his satiric
novel masquerading as nonfiction, A History of New-York from
the Beginning of the World to the End of the Dutch Dynasty, by
Diedrich Knickerbocker (1809), which took an irreverent swing
at Thomas Jefferson’s democratic ideology. Irving became the
first American writer to win the long-awaited praise from
abroad.

3. Prospectus
Evaluation of Post-discharge Telephone follow-up call with
Patients Diagnosed with COPD
Sorimar Rodríguez Morales
Walden University
2
1
1
Evaluation of Post-discharge Telephone follow-up call with
Patients Diagnosed with COPD
Problem Statement
Congestive Obstructive Pulmonary Disease (COPD)
exacerbation is a common cause for hospital admission and
readmission. Hospital admissions and readmissions negatively
impact the cost of care, costing approximately 924 million per
year (GOLD, 2017; Liu, Zhang, Li & Sun 2017). Hospital
admission and readmission costs prompted the Center for
Medicare and Medicaid to include COPD as a new readmission
measure in 2015 (Hospital Readmission Reduction Program, FY
2015). COPD readmission measure as recent new measure create
in the healthcare system the necessity to analyze what are some
of the reason that lead the patient back to the hospital. GOLD,
2017 identify that COPD exacerbation is the most common
cause of hospital admission or readmission. According to
patients, some of the reasons they visit the emergency room
including fear of disease prognosis, and lack of skills to manage

4. disease symptoms (Rising et al. 2015). This evidence show that
effort should be prioritizing to enhance patient education
integrating physical, psychological and psychosocial dimension.
In most of cases patients experiencing a COPD exacerbation is
impacting more than physical symptoms; they also experience
psychological symptoms such as anxiety and panic affecting
resulting in activity reduction that end to self-isolation
involving psychosocial dimension (Spathis, et al. 2017). Is at
this point that the primary care should focus effort to improve
and use standardizing approach to improve the patient education
and the support given to patients during the first month after
hospital discharge.
The Viera VA outpatient clinic is part of the Orlando Veterans
Administration Medical Center (OVAMC), but it is
approximately sixty miles away from Brevard County.
Therefore, patients often remain in Brevard hospitals. The Viera
outpatient clinic to support better the patient recently they
established a rapport with three community hospital systems by
improving the communication process. Now, three healthcare
system in Brevard county are sending a daily list of patients
discharged their hospitals. This improving in communication
between VA and Non-VA facilities help because nurses can
initiate coordination of care with post-discharge telephone
follow up calls to support better the patient when they are at
home after been hospital discharged.
Although the telephone follow-up call is an effective strategy,
additional efforts are needed to effect change in the patient's
self-management to decrease hospital readmission (Ko, Ngai &
Ng, 2014). The management of patient with COPD using
telephone follow up call should have a standardized approach
specific to the patient's disease (Jayakody, et al. 2016; Ko, et al
2014). However, the management of patients with COPD require
a combination of interventions because, no single intervention
is superior than other (Jayakody, et al. 2016). This project aim
to identify areas to improve, because according with the nursing
administration of the clinic there is not standardizing process to

5. follow-up after the patient with COPD get hospital discharged.
Post discharge follow-up should be specific to patient's disease
( Liu, et al 2017; Jayakody, et al. 2016; Ko, et al 2014 ). For
example, lack of specific educational activities related to
disease management is to supporting patient self-management
contributing to poor patient outcomes, such as hospital
admission or readmission (Misky, Burke, Jonson, Jones, Hanson
and Reid, 2018 ). Another are to explore is the topic of the
patient education because non-pharmacological management of
Dyspnea symptoms will impact self-management and quality of
life (Spathis, et al. 2017). Lack of education content focusing
on the management of COPD resulting in poor quality of care
and satisfaction, both are associated with lack of follow up after
discharge (Coleman, 2006; Burke et al 2013; Kripalani et al.
2014; Liu et al. 2017).
The purpose of these project is evaluate post-discharge
telephone follow-up calls activities within the first month after
hospital discharged because the identification of areas to
improve lead to provide specific interventions according to the
patient's diseases and needs (Jayakody et al. 2016; Ko et al.
2014).The goal with the post-discharge telephone follow-up call
is better support the patient by providing patient education plan
and support their with coordination of care in the use of
different resources. For example, support the patient education
will enhance self-management skills, and while monitoring their
warning symptoms during the weekly follow-up call, at this
point nurses enhancing educational material that may impact
patient's self-management skills to better management a COPD
exacerbation crisis.
Practice-Focused Question
Do the use of a standardized approach for telephone follow-up
and weekly follow-up to use with discharged patients with
COPD will reduce 10% of readmission from non-VA hospital?
or Comment by user: The question should be focus on the VA
intervention to improve readmission(green) or in my propose
intervention (red) to improve readmission?.

6. During the first 30 days post discharge, would using a standard
approach of education during telephone follow-up by the
primary care nurse for care of patients over 65 years of age who
have been diagnosed with COPD improve increasing in a 100%
of patient education giving weekly?
Social Change
The use of a standardized approach to guide nursing activities
with the patient discharge from non-VA hospitals allows the
opportunity to assess efforts made in the primary care setting to
improve the quality of care provided to the patient diagnosed
with COPD. The telephone follow-up can improve patient
outcome and satisfaction (Burke et al. 2018; Jayakody et al
2016). The use of standardized approach will help to overcome
the patient's stigma, because most of the time they denied of
having problem with disease management Kirkpatrick, 2012).
The use Breathing-Thinking-Functioning (BTF) model for
patient education and telephone follow-up will helps to design
an individualized plan of education specific to the patient's
interest and needs. Also, the BFT model support coordination
of care activities improving the use of existing resources
(Spathis et al. 2017). The use of existing resources will support
educational material resulting in risk reduction of hospital
admission or readmission throughout the post discharge
education plan include non-pharmacological and
pharmacological management (GOLD, 2017; Ko et al. 2014).
Nursing will support better the patient helping monitoring
warning symptoms during the first months after hospital
discharge. The weekly monitoring will be part of educational
reinforcement and discussion.
This project by identifying areas to improve during post-
discharge telephone follow-up call and standardized patient
education according to the patient diseases, interests and needs
will impact other Ambulatory Care Sensitive Conditions
(ACSC) such congestive Heart failure. Also, will increase
patient's satisfaction motivating the patient to become an active
participant (Lippincott, 2017).

7. The Context for the Doctoral Project
The Viera VA is one of nine satellite outpatient clinic
branches of the Orlando Veterans Administration Medical
Center (OVAMC). Annually, the Viera Clinic provides
multidisciplinary services to the veteran population who reside
in Brevard County. The Brevard County veteran population
continues to engage in a staggering number of hospital
admission/readmission. Patient education after been discharge
from Brevard hospitals will support patients by establishing the
standardizing approach for education. At the same time will
facilitate the coordination of care and the telephone follow-up
call.
The telephone follow-up call is highly recommended as a
proven strategy to use during the transition of care (Burke et al.
2018; Jayakody et al. 2016). The telephone follow-up call will
enhancing communication with patients and also with the
interdisciplinary team to include in the educational
reinforcement of educational material receiving and also to
follow up recommendations provided by the interdisciplinary
team. Evaluate the educational topic delivered by nurses and by
interdisciplinary team during the first month after the patient
have been discharged will help to justify the improvement in the
patient education is an essential part of the interventions
received after discharge.
The Viera clinic has the opportunities to improve the telephone
follow up call using BTF model. The clinic has resources to
support the patient such as mental health services, Telehealth
program, Move 101, palliative, home-based, pulmonary
rehabilitation, social services, pharmacy, among other. The
Breathing, Thinking, Functioning (BTF) model to provide
education and care coordination enhancing self-management
skill to manage a COPD exacerbation or crisis (Spathis et al.
2017) .
Source of Evidence
COPD is one of the most costly chronic diseases in the VA
health care system. Untreated COPD exacerbations are often the

8. cause for admission and readmission (GOLD, 2017). The
staggering readmission rate of patients with COPD relates to
poor post-discharge follow-ups and the lack of standardization
of process ( Coleman, 2006; Burke et al 2013; Kripalani et al.
2014; Shah, Churpek, Coca Perraillon, & Konetzka, 2015, Liu,
Zhang, Li and Sun 2017). The need for a standardized process
to guide the management of patients with COPD is clear
evidence of the inconsistency in practice.
The Breathing, Thinking, Functioning (BTF) Model model
focuses on increasing self-management support by educating
veteran about COPD including non-pharmacological skills to
assist them in managing their care in special and dyspnea crisis.
The BTF Model encompasses cognitive and behavioral
techniques during an exacerbation or crisis as the method to
alleviate the disease symptoms. The BTF model focuses on
engaging the patient in the breath, think and function while
living with a chronic illness (Bausewein et al., 2018). This
model conceptualizes breathing, thinking and functioning as a
cognitive and behavioral reaction to dyspnea during a COPD
exacerbation.
Approach
The best strategy for a program evaluation is by gathering the
existing data related to the current program and identifying
areas for improvement to ensure better outcomes (Nieswiadomy,
2012). Nieswiadomy (2012) stated that the program evaluation
approach is the fifth level of evidence. Patton (1987) declared
that evaluation is the critical process of examining a program.
Program evaluation involves the collection of information
related to the program and outcomes. The intention of
completing this process is to obtain accurate information to
produce effective decisions (Patton, 1987, p. 21). The proposed
project aims to apply the Kellogg Basic Logic model as a
systematic and visual process to collect the post-hospital
discharges follow up data.
The Kellogg Basic Logic model uses a systemative five-step
process. The first step in the model is gather information of

9. current practice using nurses, physicians, and other team
members. The second step is to explore the activities involving
the existing program and evaluate if the program is effective by
auditing existing. The study targets Quality Management post-
discharge performance measurements to monitor the COPD
patient population. The project attempts to collect performance
measure standards like timeframes and documentation of the
post-disharge call and weekly follow-up, timeframe of medical
follow-up appointment, patient education and the used of
resources.
Ethical Considerations
The Veterans Administration Central Institutional Review Board
(IRB) complies with the “Common Rule” for the protection of
human subjects. Although, the proposed project does not aim to
use the human subjects as part of the program evaluation, the
improvement measure will impact the services provided to
patients with COPD.
The data collection will start after the IRB approval. To protect
the patient’s privacy and avoid duplication of patients a code
will be assigned. Any data collected will be saved using an
electronic file password protected by VA computers. The
proposed project will follow the structured step process to
ensure that the study complies with Walden University’s Ethical
Standards and U.S Federal regulations. This proposed project
will conduct a program evaluation using patient’s information,
which is protected data within the VA research process. The
program evaluation in this project targets the second fold of the
VA Central IRB process, which explicitly specifies the
enhancement to review program process across participant sites
(VA Central Institutional Review Board (IRB), 2017).
Alignment
The proposed program evaluation project aligns with the VA
priority that includes improving the transition of care and the
standardization of care management (VA, 2018). This intended
program evaluation project targets to enhanced and
standardization of current process in the Viera clinic. The

10. efficiency of the proposed program will impact the services and
the support needed by patients with COPD post-discharge by
improving the quality of nursing care. Commonly, a structured
follow-up coordination of care covers the first 30 days of high
risk for hospital readmission period. A standardized care
coordination process will improve the communication and the
plan of care for patients with COPD. The use of standardized
approach guides nurses and promotes consistency in
intervention between patients. The provision of a patient's
education with a weekly follow up aims to improve outcomes.
The use of a standardized approach helps to increase the use of
existing community resources available (Zurlo and Zuliani,
2018). The evaluation of the telephone follow-up call helps to
identify area of oportunities for improvements (Siriwardena
2009).
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