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Capella 4900 Assessment 3

Assessment 3 – Assessing the Problem; Patient, Family, or Population Health Problem Solution

Student Name

Capella University

FPX4900: Capstone Project for Nursing



Assessing the Problem; Patient, Family, or Population Health Problem Solution

The scope of contemporary nursing is not limited to direct patient interactions. It also embraces leveraging technology, orchestrating seamless care coordination, and tapping into community resources to address patient issues. This comprehensive approach can significantly enhance patient outcomes and contribute to the overall efficiency of health care organizations. The following sections provide an in-depth analysis of how these elements can be effectively applied to manage a specific patient problem, using the case of Taylor, a heart failure patient.

Impact of Healthcare Technology on the Problem

Healthcare technology, including telehealth systems and wearable devices, has substantial potential to transform care for heart failure patients like Taylor, both by improving health outcomes and reducing hospital readmissions. In-depth studies, like the one conducted by Silva-Cardoso and colleagues (2021), have demonstrated the efficacy of telehealth monitoring systems for heart failure patients. These systems allow for remote monitoring of vital signs such as blood pressure, heart rate, and weight, which are critical indicators of health status for heart failure patients. If any of these parameters deviate from the norm, healthcare professionals can intervene promptly, potentially preventing a hospital admission.

Capella 4900 Assessment 3

Moreover, wearable health technology, such as heart rate monitors and fitness trackers, can provide real-time data to both patients and healthcare providers. This continuous monitoring can enable immediate response to any concerning changes, promoting timely interventions that could prevent hospital readmissions (Thomas et al., 2021). However, the use of healthcare technology is not without potential drawbacks. The utilization of these technologies requires a level of digital literacy that may be challenging for some patients, particularly older adults or those with limited education. This digital divide can create disparities in access to and benefits from healthcare technology (Kemp et al., 2020).

Capella 4900 Assessment 3

Privacy and security concerns are also paramount when using healthcare technology. The sensitive health information collected and transmitted by these systems could be vulnerable to breaches, potentially compromising patient confidentiality (Offner et al., 2020). In terms of costs and barriers, the financial burden of implementing advanced health technology can be substantial. These costs include not only the price of the devices themselves but also the cost of training patients and healthcare professionals to use the technology effectively. Furthermore, potential resistance to technology adoption by both patients and providers can be a significant barrier (Ralston et al., 2019).

Reflecting on my current nursing practice, these advantages and challenges align with my observations. Telehealth services, while promising, often face implementation difficulties, particularly among certain patient populations. Elderly patients or those from socioeconomically disadvantaged backgrounds often struggle with the digital literacy required to navigate these systems. Furthermore, issues of privacy and data security remain ongoing concerns in our efforts to integrate technology into patient care. Healthcare technology holds immense potential for improving patient outcomes and reducing hospital readmissions, it is crucial to address the associated challenges. Overcoming these barriers will require ongoing education and support for patients and providers, stringent data security measures, and concerted efforts to reduce disparities in digital literacy.

Role of Care Coordination and Community Resources

Effective care coordination and the strategic utilization of community resources could be pivotal in addressing Taylor’s problem of recurrent heart failure hospitalizations. Both these elements combine to form a cohesive system that promotes patient-centered care, improved health outcomes, and reduced healthcare costs. Care coordination, specifically, ensures that all healthcare professionals involved in Taylor’s care are on the same page regarding his management plan. This collaborative approach can lead to more consistent and comprehensive care, reducing the risk of hospital readmissions. A systematic review found that improved care coordination among healthcare professionals significantly reduced hospital readmissions in heart failure patients, highlighting its potential in improving Taylor’s outcomes (Ledwin & Lorenz, 2021).

Capella 4900 Assessment 3

In addition to care coordination, community resources can offer invaluable support to patients like Taylor. Heart failure support groups, for instance, can provide both emotional backing and practical advice. These groups often consist of individuals who share similar experiences, creating an environment that promotes understanding, empathy, and shared learning. Research demonstrated that participation in heart failure support groups significantly improved self-care behaviors, leading to better disease management and reduced hospitalizations (Son et al., 2020).

In my professional nursing practice, I have seen the benefits of care coordination and community resources firsthand. When all members of the healthcare team work in synergy, and when patients are connected with relevant community resources, patient satisfaction and outcomes improve noticeably. However, achieving this level of coordination and resource utilization is not without challenges. Barriers to effective care coordination include potential communication gaps among different healthcare providers, particularly in multi-disciplinary teams where each member may have their own focus and priorities. A study pointed out that effective communication is crucial in care coordination, and any breakdown could lead to suboptimal patient outcomes (Cullati et al., 2019).

Regarding community resources, potential barriers may include patients’ lack of awareness about available resources, logistical issues such as transportation to support group meetings, and potential stigma associated with participating in these groups. These issues underscore the importance of healthcare providers actively facilitating access to these resources and addressing any concerns that patients may have (Son et al., 2020). Care coordination and the utilization of community resources have significant potential to improve Taylor’s situation, it is important to recognize and address potential barriers. To achieve this, healthcare providers must be proactive in facilitating effective communication, promoting awareness of available resources, and addressing any logistical or personal barriers that may impede access to these resources (Ledwin & Lorenz, 2021).

State Board Nursing Practice Standards and Organizational/Governmental Policies

State board nursing practice standards and organizational or governmental policies provide a comprehensive framework for the application of health technology, care coordination, and the utilization of community resources. These guidelines not only define the roles and responsibilities of registered nurses but also set the parameters for ethical and professional practice.

One of the key policy documents that guide nursing practice is the Nursing Practice Acts. These acts provide the legal foundation for nursing practice and define the roles and responsibilities of registered nurses, including their role in coordinating care and utilizing technology in patient care (Dickison et al., 2019). For instance, these acts often stipulate the necessity for nurses to coordinate with other healthcare professionals, advocate for the patient, and utilize available resources, including technology, to provide optimal patient care (Liu et al., 2021).

Another key piece of legislation that impacts the scope of nursing practice, particularly in the context of healthcare technology, is the “Health Insurance Portability and Accountability Act (HIPAA)”. This federal law sets the standard for protecting sensitive patient data, ensuring that patient information remains confidential as it’s shared across different healthcare platforms (Williams & Colomb, 2020). This legislation plays a crucial role in regulating the use of health technology such as electronic health records and telehealth platforms, ensuring that patient privacy is not compromised.

From an ethical perspective, the “American Nurses Association (ANA)” Code of Ethics provides guidance for professional nursing practice, emphasizing principles like maintaining patient confidentiality, obtaining informed consent, and advocating for patient rights (Chism, 2021). These ethical principles inform the approach to addressing Taylor’s problem through the use of applied technology, care coordination, and community resources. For instance, in implementing telehealth technology for Taylor, it would be crucial to obtain his informed consent, ensuring that he understands the benefits, risks, and privacy implications of this technology (Williams & Colomb, 2020).

Documenting the practicum hours spent with Taylor and his healthcare team in the CORE ELMS Volunteer Experience Form is also an essential part of this process, providing a record of the time invested in exploring these aspects of his care. Over the course of two hours, I engaged directly with Taylor, his healthcare team, and consulted with industry experts to determine how best to apply healthcare technology, care coordination, and community resources to his situation.

The Nursing practice standards, policies, and ethics provide a vital roadmap for addressing Taylor’s situation. These guidelines not only shape the scope of nursing practice but also ensure the provision of ethical, patient-centered care. By adhering to these standards and policies, we can ensure that Taylor receives the most effective, ethical, and coordinated care possible.


In the evolving landscape of healthcare, adopting a multi-faceted approach involving technology, coordinated care, and community resources is indispensable. This approach not only aligns with state board nursing practice standards and policies but also ensures ethical and comprehensive care. By using the case of Taylor, it’s clear how these strategies can create a substantial difference in managing chronic conditions such as heart failure. However, understanding and addressing potential barriers is crucial to fully leveraging these strategies in practice. The integration of these elements into healthcare practices holds the promise of improved patient outcomes, reduced healthcare costs, and enhanced quality of care.


Chism, L. A. (2021). The doctor of nursing practice: A guidebook for role development and professional issues. In Google Books. Jones & Bartlett Learning. 

Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten quality of care: a study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. 

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the national council of state boards of nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72–78. 

Kemp, E., Trigg, J., Beatty, L., Christensen, C., Dhillon, H. M., Maeder, A., Williams, P. A. H., & Koczwara, B. (2020). Health literacy, digital health literacy, and the implementation of digital health technologies in cancer care: The need for a strategic approach. Health Promotion Journal of Australia, 32(S1). 

Ledwin, K. M., & Lorenz, R. (2021). The impact of nurse-led community-based models of care on hospital admission rates in heart failure patients: An integrative review. Heart & Lung, 50(5), 685–692. 

Liu, X., Xu, Y., Chen, Y., chen, C., Wu, Q., Xu, H., Zhu, P., & Waidley, E. (2021). Ethical dilemmas faced by frontline support nurses fighting COVID-19. Nursing Ethics, 096973302110152. 

Offner, K. L., Sitnikova, E., Joiner, K., & MacIntyre, C. R. (2020). Towards understanding cybersecurity capability in Australian healthcare organisations: A systematic review of recent trends, threats and mitigation. Intelligence and National Security, 35(4), 556–585. 

Ralston, A. L., Andrews, A. R., & Hope, D. A. (2019). Fulfilling the promise of mental health technology to reduce public health disparities: Review and research agenda. Clinical Psychology: Science and Practice, 26(1). 

Silva-Cardoso, J., González Juanatey, J. R., Comin-Colet, J., Sousa, J. M., Cavalheiro, A., & Moreira, E. (2021). The Future of Telemedicine in the Management of Heart Failure Patients. PubMed Central (PMC). 

Son, Y.-J., Choi, J., & Lee, H.-J. (2020). Effectiveness of nurse-led heart failure self-care education on health outcomes of heart failure patients: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(18), 6559.

Thomas, E. E., Taylor, M. L., Banbury, A., Snoswell, C. L., Haydon, H. M., Gallegos Rejas, V. M., Smith, A. C., & Caffery, L. J. (2021). Factors influencing the effectiveness of remote patient monitoring interventions: A realist review. BMJ Open. 

Williams, K., & Colomb, P. (2020). Important considerations for the institutional review board when granting health insurance portability and accountability act authorization waivers. Ochsner Journal, 20(1), 95–97. 

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