Dnp Proposal

M. KELLY DNP PROJECT PROPOSAL

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PROJECT DESCRIPTION The purpose of this project is to positively influence the direction of nursing practice through development of a plan for implementing and disseminating care transitions learning tools among nurses, based on findings from a survey assessing nurse knowledge-attitude-practice (KAP) of the Care Transitions Intervention four pillars. The Care Transitions Intervention (CTI) model, developed by the Care Transitions Program (Parry, Coleman, Smith, Frank & Kramer, 2003) is an evidence-based, fourweek intervention designed to decrease hospital readmissions while empowering and supporting patients to take a more active role in managing their health care. To design tools that promote and build core nursing practice competencies in care transitions, more information about nursing level of knowledge in this critical area is needed. The unique goal of this project is to survey nurses about care transitions issues and the essential patient-centered components contained in the CTI, including: a) a “personcentered health record, PHR” (the patient utilizes the PHR to facilitate communication across providers and settings); b) medication self-management (the patient knows who and what to ask to resolve medication discrepancies or concerns; c) knowledge of red flags (patient is knowledgeable about his or her health condition warning signs and has a plan to address them; if patient is not knowledgeable, patient understands the importance of reviewing red flags with his or her medical provider) and d) primary care/specialist follow-up (patient is knowledgeable about his or her health condition warning signs and has a plan to address them). Approximately sixty nurses will participate in the survey. Survey responses will be analyzed to identify, thematically, the predominant learning needs of nurses who might participate in implementation of the CTI. This project is the first phase of a multi-tiered initiative to promote nursing practice to improve the quality of care for people with chronic disease. OBJECTIVES •

Identify and summarize nurse understanding of key care transition issues and attitudes toward, interest in, and capacity for integrating the principles of the CTI model.

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Develop a framework for nurses to learn and practice the principles of CTI for nurses in various settings based on the survey findings.

• Increase the ability of practicing nurses to include patients and families in management of chronic disease outside of the hospital setting. PROJECT OUTCOME Sixty nurses in California will complete the Care Transitions knowledge-attitude & practice (KAP) survey. Results will be analyzed for major themes, which will guide the design and implementation of future activities that build on care transition competencies in nursing practice in California.

M. KELLY DNP PROJECT PROPOSAL

PROJECT MILESTONE 1. Develop survey 2. Pilot survey 2. Conduct KAP survey 4. Analyze/evaluate 5. Summarize findings

TIMELINE 09-15-09 to 12-0109

ACTIVITIES & APPROACHES

October 2009

Develop survey questionnaire.

October 2009

Pilot survey questionnaire on ten nurses, analyze quality of results. Redesign and pilot again as needed. Attend California Institute of Nursing and Health Care (CINHC) conference. Have booth set up to invite nurses to participate in survey. Have incentives available. Analyze survey results of Care Transitions. Use coding to identify predominate themes in responses. Evaluate themes for clarification of barriers and opportunities to the implementation of care transitions learning activities. Design plan for implementation and dissemination of Care Transitions learning tools, which include components for sustainability. *Comprehensive Report of Project to Committee *Present DNP Project

November 2-3 November 4-7 November 8-16 November 19th

7. Finalize report 6. Present/defend

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December 8th am 2009

Note * items are final DNP degree requirements. INIATIVE OUTCOME To positively influence the direction of nursing practice by providing opportunities for nurses to integrate the Care Transitions Intervention into the professional nursing roles and practice. As nurses become competent in safely transitioning clients with chronic disease between care settings, it may be possible to increase quality of life, reduce health care costs and support clients’ capacity for autonomy through self-care. SURVEY EVALUATION Categorical and open-ended questions will be employed in the survey design; responses will be reviewed and evaluated using thematic analysis. REFERENCES Parry, C., Coleman, E., Smith, J., Frank J., & Kramer, A. (2004). Preparing Patients and Caregivers to Participate in Care Delivered Across setting: The Care Transitions Intervention. Journal of the American Geriatrics Society, 52(11), 1817-1125.