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Capella Nursing Samples

Capella 4900 Assessment 4

Assessment 4: Patient, Family, or Population Health Problem Solution

Student Name

Capella University

FPX4900: Capstone Project for Nursing



Patient, Family, or Population Health Problem Solution

This capstone project focuses on improving the management of heart failure for a patient named Taylor. After a thorough examination of Taylor’s case in the first three assessments, several key issues were identified, including gaps in care coordination, lack of patient involvement in care, and suboptimal use of technology and community resources. These issues were analyzed from various perspectives such as leadership, collaboration, communication, change management, policy, quality of care, patient safety, costs to the system and individual, technology, care coordination, and community resources. The goal now is to propose a comprehensive intervention that addresses these issues, enhances Taylor’s health outcomes, and provides a model for managing similar cases in the future.

Role of Leadership and Change Management in Addressing the Problem

Leadership is an essential part of the healthcare system, and it played a significant role in identifying and addressing Taylor’s recurrent heart failure hospitalizations. As a nurse leader, my role encompassed directing the multidisciplinary team toward a unified goal – improving Taylor’s health outcomes. In this context, leadership strategies such as clear communication, delegation of tasks, and fostering a collaborative environment were employed (Abshire Saylor et al., 2023).

Change management is another crucial factor in implementing the proposed intervention. Effective change management includes identifying the need for change, developing a robust plan, communicating the change, and evaluating the impact (Kotharkar & Ghosh, 2022). In Taylor’s case, change was needed to improve his health status. The current care plan was not effectively preventing hospital readmissions, which indicated a need for a different approach. I proposed an intervention integrating telehealth monitoring systems and wearable devices for constant monitoring of Taylor’s vital signs, and a coordinated care plan involving all healthcare professionals involved in his care (Krzesiński, 2023).

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Change management strategies were used to help the healthcare team understand and adapt to this new approach. This included explaining the benefits of the proposed intervention, providing training on the use of telehealth systems and wearable devices, and ensuring everyone understood their roles in the new care plan. Regular meetings were also held to address any concerns or resistance from the team, ensuring smooth implementation of the change (Krzesiński, 2023).

In developing the proposed intervention, nursing ethics were a guiding principle. The core values of nursing ethics include autonomy, beneficence, nonmaleficence, justice, and fidelity (Ilkafah et al., 2023). In the context of Taylor’s case, patient-centered care was prioritized, meaning Taylor’s needs, preferences, and values were taken into account when designing his new care plan. Confidentiality was upheld in using telehealth systems and wearable devices, ensuring that Taylor’s health information was protected. Informed consent was obtained from Taylor, ensuring that he understood the benefits, risks, and privacy implications of the proposed intervention (Krzesiński, 2023).

The intervention included a new care plan incorporating telehealth systems, wearable devices, and a coordinated approach involving all healthcare professionals involved in Taylor’s care (Ilkafah et al., 2023). The goal of the intervention was to provide more effective, personalized care to Taylor, reduce his hospital readmissions, and improve his overall health outcomes. By embracing the role of leadership, change management, and nursing ethics, we ensured that the proposed intervention was not only effective but also ethical and aligned with professional standards (Krzesiński, 2023).

Strategies for Communicating and Collaborating with the Patient, Family, or Group

The primary stakeholders in this intervention are Taylor and his family as they are directly and most significantly impacted. Their perspective, informed by their daily experiences with Taylor’s health management, provides unique insights that can greatly contribute to the formulation of a successful intervention plan. Engaging them in the decision-making process ensures that the intervention is tailored to their needs and circumstances. Their input is vital as it not only shapes the intervention but also fosters a sense of ownership, thus increasing their commitment to the intervention’s success (Shepherd, 2020). Furthermore, their involvement encourages patient-centered care, a fundamental nursing ethic that promotes autonomy, respect, and empowerment (Ilkafah et al., 2023).

To communicate and collaborate effectively, several best-practice strategies supported by the literature can be utilized. Active listening is paramount; it involves paying undivided attention to Taylor and his family during discussions, showing understanding, and acknowledging their input (Kingsbury et al., 2020). This approach fosters a therapeutic relationship, crucial for shared decision-making, which is another essential strategy. Shared decision-making is a collaborative process that recognizes the importance of Taylor’s active involvement in his care. It considers his preferences and values, and together with the healthcare team, an informed and mutually agreed decision is made (Shepherd, 2020).

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Lastly, providing culturally sensitive care is of utmost importance. This involves understanding and respecting the cultural values, beliefs, and practices of Taylor and his family. By incorporating culturally appropriate language and considering their health beliefs in the care plan, we enhance our communication and collaboration. This respectful and inclusive approach contributes significantly to the success of the proposed intervention, ultimately promoting better health outcomes for Taylor (Hultsjö et al., 2019).

State Board Nursing Practice Standards and Organizational/Governmental Policies

The development of the proposed intervention was significantly guided by certain specific nursing practice standards and policies. These included the “Nursing Practice Acts (NPAs)” and the “Health Insurance Portability and Accountability Act (HIPAA)”. The NPAs, which define the legal scope of nursing practice, were crucial in ensuring that the proposed intervention aligns with the expectations and regulations of the nursing profession. Specifically, the standards pertaining to patient advocacy, safety, and quality care informed the design of the intervention and emphasized the need for an individualized, patient-centered approach (Cahill et al., 2019).

Furthermore, HIPAA’s guidelines regarding the privacy and security of patient health information were instrumental in shaping the intervention. Ensuring compliance with these standards was a key consideration, especially given the proposed use of technology in Taylor’s care. The intervention includes measures to protect Taylor’s personal health information in accordance with HIPAA’s regulations, such as using secure platforms for telehealth appointments and encrypted digital systems for electronic health records (Esmaeilzadeh & Mirzaei, 2019).

Importantly, research has validated the effectiveness of these standards and policies in improving patient outcomes. Studies have shown that adherence to NPAs and HIPAA guidelines not only enhances the quality of care but also boosts patient trust and satisfaction. By ensuring confidentiality and respecting patient autonomy, these standards support a safe, respectful, and effective care environment (Abshire Saylor et al., 2023). Thus, their integration into the proposed intervention is expected to significantly contribute to the success of Taylor’s care plan, enhancing his health outcomes and overall wellbeing (Esmaeilzadeh & Mirzaei, 2019).

Improvement in Quality of Care, Patient Safety, and Cost Reduction

The proposed intervention is specifically designed to significantly enhance the quality of care that Taylor receives. Central to this improvement is the incorporation of telehealth for enhanced patient monitoring. According to studies like the one conducted by Krzesiński (2023), this technology facilitates early detection of changes in a patient’s health status. Early detection enables prompt responses to health deterioration, reducing the risk of acute health crises and unnecessary hospitalizations.

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The preventative nature of this approach improves patient safety. It also minimizes stress for the patient and their family, and mitigates the risk of hospital-acquired infections, as supported by Shara and colleagues (2022). The intervention also emphasizes better care coordination via a multidisciplinary care team, aligning with best practices outlined by Cui and coworkers (2019). Each team member brings their unique expertise and knowledge to the table, fostering a comprehensive approach to Taylor’s care.

Benchmark data from the National Quality Forum underscores the importance of such coordinated care in improving patient outcomes and reducing healthcare costs. Moreover, the intervention encourages Taylor and his family to actively participate in his care. This approach, which is backed by a study by Fu and colleagues (2023), enhances their understanding of his health conditions and empowers them to make informed decisions, leading to improved patient satisfaction, adherence to care plans, and overall health outcomes.

Regarding safety, the proposed intervention’s focus on telehealth and early detection is critical. These strategies have been shown to minimize the risks associated with severe health crises. As for costs, the ability of the intervention to prevent unnecessary hospitalizations has significant implications for healthcare savings, both at the system and individual level. The “Agency for Healthcare Research and Quality” cites these strategies as effective in reducing healthcare costs, further reinforcing the findings by Shara and colleagues (2022).

Lastly, the use of telehealth and home-based care can reduce transportation and other associated costs of hospital visits. Therefore, the proposed intervention, through its focus on telehealth, multidisciplinary care, and patient participation, is expected to significantly enhance Taylor’s care quality, safety, and cost-effectiveness (Krzesiński, 2023).

Application of Technology, Care Coordination, and Community Resources in Addressing the Problem

Technology plays a vital role in addressing Taylor’s health problem. The proposed intervention utilizes telehealth and wearable health technology, which not only facilitate remote patient monitoring but also provide real-time health data. These technologies enable prompt intervention when needed and promote patient involvement in their own care. According to a study, the application of these technologies has proven effective in improving outcomes for heart failure patients (Krzesiński, 2023).

Care coordination is another crucial aspect of the intervention. A multidisciplinary team approach is incorporated to ensure comprehensive and coordinated care for Taylor. Each team member contributes their expertise, fostering a collaborative environment that addresses all aspects of his health needs. Cui and colleagues (2019) demonstrated that effective care coordination reduces hospital readmissions and improves health outcomes in heart failure patients.

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Lastly, the proposed intervention connects Taylor with valuable community resources, such as support groups and exercise programs. These resources enhance self-care behaviors and provide emotional support, both of which are critical for managing chronic conditions like heart failure. Howarth and colleagues (2020) found that access to community resources positively impacts the overall well-being of patients living with chronic conditions. The incorporation of technology, care coordination, and community resources in the proposed intervention is well-supported by the literature, and together, they form a comprehensive approach to addressing Taylor’s health problem (Fu et al., 2023).


The proposed intervention, developed after careful consideration of Taylor’s needs and the current gaps in his care, presents a multifaceted approach to managing heart failure. It incorporates leadership strategies, change management, ethical considerations, effective communication, collaboration, adherence to nursing practice standards, policies, quality of care, patient safety, cost-effectiveness, technology, care coordination, and utilization of community resources. Each aspect of this intervention is supported by credible evidence and is expected to produce tangible, measurable results for Taylor. Going forward, the intervention will be reviewed by faculty, and upon approval, it will be implemented, marking the next step in Taylor’s journey towards improved health and quality of life.


Cahill, M., Gleason, K., Harkless, G., Stanley, J., & Graber, M. (2019). The regulatory implications of engaging registered nurses in diagnoses. Journal of Nursing Regulation, 10(2), 5-10.

Cui, X., Zhou, X., Ma, L. L., Sun, T. W., Bishop, L., Gardiner, F. W., & Wang, L. (2019). A nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: A randomized and controlled trial in China. Rural and remote health, 19(2), 1-8.

Esmaeilzadeh, P., & Mirzaei, T. (2019). The potential of blockchain technology for health information exchange: Experimental study from patients’ perspectives. Journal of medical Internet research, 21(6), e14184.

Fu, B. Q., Zhong, C. C., Wong, C. H., Ho, F. F., Nilsen, P., Hung, C. T., Yeoh, E. K., & Chung, V. C. (2023). Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: Systematic review of qualitative studies. International Journal of Health Policy and Management, 12(Continuous), 1–17.

Howarth, M., Brettle, A., Hardman, M., & Maden, M. (2020). What is the evidence for the impact of gardens and gardening on health and well-being: A scoping review and evidence-based logic model to guide healthcare strategy decision making on the use of gardening approaches as a social prescription. BMJ open, 10(7), e036923.

Hultsjö, S., Bachrach-Lindström, M., Safipour, J., & Hadziabdic, E. (2019). “Cultural awareness requires more than theoretical education”-Nursing students’ experiences. Nurse Education in Practice, 39, 73-79.

Ilkafah, I., Anestasia Pangestu, M. T., & Rini, R. (2023). The ethical principles and caring behavior of Indonesian nurses. Healthcare in Low-resource Settings, 11(S2).

Kotharkar, R., & Ghosh, A. (2022). Progress in extreme heat management and warning systems: A systematic review of heat-health action plans (1995-2020). Sustainable Cities and Society, 76, 103487.

Kingsbury, C. G., Sibert, E. C., Killingback, Z., & Atchison, C. L. (2020). “Nothing about us without us:” The perspectives of autistic geoscientists on inclusive instructional practices in geoscience education. Journal of Geoscience Education, 68(4), 302-310.

Krzesiński, P. (2023). Digital health technologies for post-discharge care after heart failure hospitalisation to relieve symptoms and improve clinical outcomes. Journal of Clinical Medicine, 12(6), 2373.

Abshire Saylor, M., Clair, C. A., Curriero, S., DeGroot, L., Nelson, K., Pavlovic, N., Taylor, J., Gallo, J. J., & Szanton, S. (2023). Analysis of action planning, achievement and life purpose statements in an intervention to support caregivers of persons with heart failure. Heart & Lung, 61, 8–15. 

Shepherd, V. (2020). An under-represented and underserved population in trials: Methodological, structural, and systemic barriers to the inclusion of adults lacking capacity to consent. Trials, 21(1), 1-8.

Shara, N., Bjarnadottir, M. V., Falah, N., Chou, J., Alqutri, H. S., Asch, F. M., Anderson, K. M., Bennett, S. S., Kuhn, A., Montalvo, B., Sanchez, O., Loveland, A., & Mohammed, S. F. (2022). Voice activated remote monitoring technology for heart failure patients: Study design, feasibility and observations from a pilot randomized control trial. PLOS ONE, 17(5), e0267794. 

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