Assessment 1: Assessing the Problem: Leadership, Collaboration, Communication, Change Management, and Policy Considerations

Student Name 

Capella University

NURS-FPX 4900: Capstone Project for Nursing

Professor Name

Date

Introduction to the Focused Problem and its Relevance

This report aims to investigate the issue of elevated readmission rates for heart failure patients within 30 days of discharge at our healthcare institution. Evaluating this problem through the lenses of leadership, collaboration, communication, change management, and policy is essential for fostering successful transformations within the healthcare environment. Taylor is a 68-year-old male suffering from heart failure, hypertension, and chronic kidney disease. His history includes multiple hospitalizations for heart failure exacerbations. Despite receiving treatment and medication adjustments during each hospital stay, his condition remains poorly managed, leading to recurrent readmissions. His family is concerned about the emotional and financial burden caused by these frequent hospitalizations. This situation raises the question of why heart failure management is so important and what can go wrong when it is inadequately addressed within the organization.

Improper management of heart failure and hypertension can lead to severe complications, such as stroke, kidney failure, and even death. This issue not only affects the patient’s quality of life and well-being but also impacts the healthcare organization’s performance, reputation, and revenue due to the increased readmission rates (Zaki et al., 2020). Taylor has a history of smoking, which exacerbates his existing health conditions. Although he has quit smoking, the damage has already contributed to his heart failure and hypertension (Peña et al., 2021). His last visit to our hospital was three weeks ago, and he was discharged with adjusted medications and follow-up appointments. However, his condition has not improved significantly since the previous visit.

As a baccalaureate-prepared nurse, it is my duty to facilitate patients suffering from chronic conditions like heart failure and ensure they receive proper and comprehensive care (Tharani et al., 2021). This responsibility involves working with the interdisciplinary team to develop and implement evidence-based interventions aimed at reducing readmission rates and improving patient outcomes (Peña et al., 2021). By addressing this issue, I will strive to help patients like Taylor adopt healthier lifestyle behaviors and better manage their chronic conditions, ultimately enhancing their quality of life and reducing the burden on our healthcare organization.

Literature Analysis and Criteria to Evaluate the Sources

A thorough analysis of peer-reviewed literature and professional sources reveals that high hospital readmission rates for heart failure patients are attributable to various factors. These factors include inadequate discharge planning, insufficient patient education, lack of timely follow-up care, and suboptimal management of comorbidities like hypertension and chronic kidney disease (Fitch et al., 2019; Ziaeian & Fonarow, 2020). Recent studies in the literature emphasize the importance of evidence-based nursing interventions to reduce readmission rates. Such interventions include nurse-led transitional care programs, nurse-driven patient education, nursing involvement in multidisciplinary teams, telehealth monitoring, and individualized patient-centered care (Howington-Carlin, 2021). These interventions have demonstrated success in improving patient outcomes, reducing readmissions, and enhancing the overall patient experience.

Barriers to implementing evidence-based nursing practice for addressing high readmission rates include limited resources, time constraints, resistance to change, lack of nursing staff training, and insufficient support from leadership (Fu et al., 2023). Additionally, barriers to implementing theoretical guiding frameworks, such as inadequate understanding of the frameworks among nursing staff and challenges in integrating them into nursing practice, can hinder their effective application.

Overcoming these barriers requires strong nursing leadership, effective communication, and collaboration among healthcare professionals. The literature highlights the importance of applying nursing theories and conceptual frameworks to guide nursing actions and interventions during the practicum. One such framework particularly relevant for nurses is the Chronic Care Model (CCM), which emphasizes proactive, patient-centered, and team-based care to improve chronic disease management (Aekplakorn et al., 2021; Liddy et al., 2019). By applying the CCM, nursing actions can be directed towards promoting self-management support, enhancing care coordination, and facilitating better management of chronic conditions, ultimately reducing readmission rates for heart failure patients.

State Board Nursing Practice Standards and Policies

State board nursing practice standards and organizational or governmental policies can significantly impact the problem of high readmission rates for heart failure patients. For instance, nursing scope of practice, patient-to-nurse ratios, and documentation requirements can influence the quality of care provided and the ability to implement evidence-based interventions (Bartmess et al., 2021). Policies that govern nursing scope of practice, such as the Nursing Practice Acts, can either support or limit nurses’ abilities to provide comprehensive care and implement evidence-based practices. In some states, nursing practice acts define the scope of practice for registered nurses, which may include the ability to assess, plan, implement, and evaluate care for heart failure patients (Hughes et al., 2022). Additionally, state regulations may determine the acceptable patient-to-nurse ratios, which directly affect the workload and ability of nurses to deliver comprehensive and patient-centered care (Waterfield & Barnason, 2022). For example, a state policy that mandates higher patient-to-nurse ratios might result in nurses having less time to spend on patient education, discharge planning, and follow-up care, which could contribute to increased readmission rates for heart failure patients (Charosaei et al., 2022).

Organizational policies, such as adherence to evidence-based heart failure treatment guidelines and protocols, can promote consistent care and reduce the risk of readmissions. The “American College of Cardiology” and “American Heart Association” provide guidelines for the management of heart failure, which, when incorporated into organizational policies, can support better patient outcomes (Bozkurt et al., 2021; Naidu et al., 2022). Research on the effectiveness of these standards and policies in improving patient outcomes for heart failure readmissions has shown mixed results, highlighting the need for further investigation and policy development (Awan et al., 2019). The literature also emphasizes the critical role of nurses in policy-making to improve outcomes, prevent illness, and reduce hospital readmissions (Son et al., 2020).

Leadership Strategies for the Focused Problem

To address high readmission rates for heart failure patients and improve outcomes, patient-centered care, and the patient experience, several leadership strategies can be proposed. First, fostering interdisciplinary collaboration is crucial. Nurse leaders can facilitate interdisciplinary teamwork by promoting a culture of openness and communication among healthcare providers, including physicians, pharmacists, dietitians, and social workers. Collaborative care can lead to more comprehensive and coordinated interventions, ultimately improving patient outcomes (Campbell et al., 2020).

Second, empowering nursing staff through education and professional development is essential. Nurse leaders can encourage and support ongoing education and training to enhance nursing competencies related to heart failure management. This can help build a knowledgeable and skilled nursing workforce capable of delivering high-quality care (King et al., 2020). Third, implementing data-driven decision-making processes can be highly beneficial. Nurse leaders can use data analytics and quality improvement initiatives to identify areas of improvement, monitor progress, and assess the impact of interventions on readmission rates. This evidence-based approach can facilitate targeted and effective strategies to reduce readmissions (Arensberg et al., 2022).

Finally, advocating for policy changes and resource allocation is essential. Nurse leaders can work with hospital administration, local and national policymakers, and other stakeholders to advocate for policies and resource allocation that support evidence-based practices aimed at reducing readmission rates for heart failure patients. This can include lobbying for better staffing ratios, increased funding for transitional care programs, and improved access to specialized care (Kitko et al., 2020).

During my practicum, I will document the time spent with heart failure patients, their families, and interdisciplinary team members in the Core Elms Volunteer Experience Form. This documentation will ensure that I meet the required practicum hours and demonstrate my commitment to addressing this pressing issue.

Conclusion

In conclusion, tackling high readmission rates for heart failure patients requires a comprehensive approach involving evidence-based practices, nursing practice standards, and effective leadership strategies. By working collaboratively with interdisciplinary teams, we can enhance patient outcomes, patient-centered care, and the overall patient experience while reducing readmissions and improving healthcare quality. Furthermore, it is vital to remain current with scholarly literature and professional sources to ensure the implementation of the latest evidence-based practices. Engaging patients and their families in decision-making and care management also plays a crucial role in addressing this pressing issue and promoting positive healthcare outcomes.

References

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Arensberg, M. B., Brunton, C., Richardson, B., & Bolhack, S. (2022). The case for malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US skilled nursing facilities. Healthcare, 10(3), 549. https://doi.org/10.3390/healthcare10030549 

Awan, S. E., Bennamoun, M., Sohel, F., Sanfilippo, F. M., & Dwivedi, G. (2019). Machine learning‐based prediction of heart failure readmission or death: Implications of choosing the right model and the right metrics. ESC Heart Failure, 6(2), 428–435. https://doi.org/10.1002/ehf2.12419 

Bartmess, M., Myers, C. R., & Thomas, S. P. (2021). Nurse staffing legislation: Empirical evidence and policy analysis. Nursing Forum, 56(3). https://doi.org/10.1111/nuf.12594 

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