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Develop an intervention (your capstone project), as a solution to the patient, family, or population problem you’ve defined. Submit the proposed intervention to the faculty for review and approval. This solution needs to be implemented (shared) with your patient, family, or group. You are not to share your intervention with your patient, family, or group or move on to Assessment 5 before your faculty reviews/approves the solution you submit in Assessment 4. In a separate written deliverable, write a 5-7 page analysis of your intervention.Please submit both your solution/intervention and the 5-7 page analysis to complete Assessment 4.Introduction

In your first three assessments, you applied new knowledge and insight gleaned from the literature, from organizational data, and from direct consultation with the patient, family, or group (and perhaps with subject matter and industry experts) to your assessment of the problem. You’ve examined the problem from the perspectives of leadership, collaboration, communication, change management, policy, quality of care, patient safety, costs to the system and individual, technology, care coordination, and community resources. Now it’s time to turn your attention to proposing an intervention (your capstone project), as a solution to the problem.Preparation

In this assessment, you’ll develop an intervention as a solution to the health problem you’ve defined. To prepare for the assessment, think about an appropriate intervention, based on your work in the preceding assessments, that will produce tangible, measurable results for the patient, family, or group. In addition, you might consider using a root cause analysis to explore the underlying reasons for a problem and as the basis for developing and implementing an action plan to address the problem. Some appropriate interventions include the following:

Creating an educational brochure.

Producing an educational voice-over PowerPoint presentation or video focusing on your topic.

Creating a teaching plan for your patient, family, or group.

Recommending work process or workflow changes addressing your topic.

Plan to spend at least 3 direct practicum hours working with the same patient, family, or group.In addition, you may wish to complete the following:

Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete and how it will be assessed.

Conduct sufficient research of the scholarly and professional literature to inform your work and meet scholarly expectations for supporting evidence.

Note: Remember that you can submit all, or a portion of, your draft assessment to

Smarthinking

for feedback, before you submit the final version. If you plan on using this free service, be mindful of the turnaround time of 24-48 hours for receiving feedback.Instructions

Complete this assessment in two parts: (a) develop an intervention as a solution to the problem and (b) submit your proposed intervention, with a written analysis, to your faculty for review and approval.Part 1

Develop an intervention, as a solution to the problem, based on your assessment and supported by data and scholarly, evidence-based sources.Incorporate relevant aspects of the following considerations that shaped your understanding of the problem:

Leadership.

Collaboration.

Communication.

Change management.

Policy.

Quality of care.

Patient safety.

Costs to the system and individual.

Technology.

Care coordination.

Community resources.

Part 2

Submit your proposed intervention to your faculty for review and approval.In a separate written deliverable, write a 5-7 page analysis of your intervention.

Summarize the patient, family, or population problem.

Explain why you selected this problem as the focus of your project.

Explain why the problem is relevant to your professional practice and to the patient, family, or group.

In addition, address the requirements outlined below. These requirements correspond to the scoring guide criteria for this assessment, so be sure to address each main point. Read the performance-level descriptions for each criterion to see how your work will be assessed. In addition, note the additional requirements for document format and length and for supporting evidence.

Define the role of leadership and change management in addressing the problem.

Explain how leadership and change management strategies influenced the development of your proposed intervention.

Explain how nursing ethics informed the development of your proposed intervention.

Include a copy of the intervention/solution/professional product.

Propose strategies for communicating and collaborating with the patient, family, or group to improve outcomes associated with the problem.

Identify the patient, family, or group.

Discuss the benefits of gathering their input to improve care associated with the problem.

Identify best-practice strategies from the literature for effective communication and collaboration to improve outcomes.

Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of your proposed intervention.

Cite the standards and/or policies that guided your work.

Describe research that has tested the effectiveness of these standards and/or policies in improving outcomes for this problem.

Explain how your proposed intervention will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.

Cite evidence from the literature that supports your conclusions.

Identify relevant and available sources of benchmark data on care quality, patient safety, and costs to the system and individual.

Explain how technology, care coordination, and the utilization of community resources can be applied in addressing the problem.

Cite evidence from the literature that supports your conclusions.

Write concisely and directly, using active voice.

Apply APA formatting to in-text citations and references.

1
Assessing the Problem: Quality, Safety, and Cost Considerations
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date of Submission
2
Assessing the Problem: Quality, Safety, and Cost Considerations
Introduction
The quality of care is a critical consideration for patients, especially those who reside in
vulnerable urban and rural areas. Healthcare providers focus on the degree of service that
increases the chances of desired and positive outcomes. The healthcare quality concept
encompasses care effectiveness that utilizes the best available evidence-based practices to
control major health problems. According to Zhang et al. (2021), providing high-quality
healthcare is followed closely by safety, and reducing costs to make care services affordable,
equitable, efficient, and timely. Healthcare quality, safety, and care cost consideration affect the
management of Ventilator-Associated Pneumonia as evidenced by a case study patient in this
assessment.
Part 1
Previous studies including that of Wu et al. (2019), and Kharel, Bist, and Mishra (2021)
have demonstrated the value of education in managing and improving Ventilator-Associated
Pneumonia care as well as identifying gaps affecting this problem’s care management. These
studies also indicate that inadequate delivery of patient education or not providing education to
patients in totality affects the overall outcomes of a healthcare system. Care help offered by care
providers is integral to VAP treatment compliance as well as lifestyle changes required to
improve patient care. According to Kharel et al. (2021), the inability of physicians and nurses to
equip patients with strategies and information needed to engage in effective VAP management
results in undesired outcomes and poor disease management. Thus, inappropriate management of
3
Ventilator-Associated Pneumonia leads to disease burden, impacts the quality of care, healthcare
cost considerations, safety, and undesired outcomes.
Quality of Care, Safety, and Cost of Care in Ventilator-Associated Pneumonia
Management
In Ventilator-Associated Pneumonia management, healthcare providers play an essential
role in high care quality which is provided through telehealth technology and programs such as
Pay-For-Performance to improve the management of VAP. According to Álvarez-Lerma et al.
(2018), timely and comprehensive patient education for individuals with VAP is critical in
improving the quality of care, reducing costs, and supporting patient safety. In practice,
providing patient education ensures a high-quality care standard while considering the safety of
the patient both at the hospital and at home. Patient education that focuses on routine screening,
active self-management, preventive care, and effective communication forms essential strategies
that guarantee safety and quality in the care of patients with Ventilator-Associated Pneumonia.
As a way to ensure effective patient education as well as improved care and safety for VAP
patients, primary care providers opt for interdisciplinary collaboration that allows them to share
expertise and knowledge and establish a strong interpersonal relationship with the patient and
other physicians to improve patient’s satisfaction. Care cost has been an issue in managing VAP
since untimely interventions may cause ventilator-associated pneumonia to escalate to other
respiratory problems such as Covid-19, pulmonary hypertension, and asthma, and this increases
care costs (Seth, 2020).
Nurses have a critical role in managing care, performance, and care outcomes of VAP.
As such, they aid in implementing working strategies that improve the safety and quality of
patient care. Kharel et al. (2021) examined estimations of VAP prevalence by World Health
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Organization and determined that the burden of providing care for this disease will continue to
increase and will not only weigh down nurse practitioners but also increase the cost of care.
Particularly, the authors highlighted that the disease burden will increase to 11.4% by 2030 and
further to 15.8% by 2045 (Kharel et al., 2021). These statistics indicate that instead of the burden
of the VAP problem decreasing, it will continue to increase and this calls for effective patient
care to manage health costs and increase care outcomes. Evidence-based practices that may
improve the management of VAP are providing patients with a comprehensive education during
each of their visits as well as giving them relevant resources that teach them how to manage
Ventilator-Associated Pneumonia. Implementing quality improvement strategies and resources
for patients diagnosed with chronic conditions has impacted significantly care services delivery.
These strategies aid in facilitating appointments, scheduling follow-ups, and helping patients to
manage appropriately their conditions (Papazian et al., 2020). Providers use quality improvement
strategies to determine the best practices that can improve the quality of care and reduce cost.
In practice, an encounter with George, a case study and an ICU patient who require
intubation within 48 hours in a local hospital in New York City, demonstrated how patient,
population, or family problem affects care quality, safety, and care cost to the individual and the
system. George’s experience with getting improved care from his primary care provider as well
as disease management has been below not up to his expectations and this affects his wellbeing.
Based on the sessions held with him, he explained that his nurse practitioner made little effort in
helping him manage the disease except for prescribing Antipseudomonal Carbapenems drugs.
Notably, the case-patient noted that his primary caregiver did not have any education on lifestyle
changes and other relevant modifications to improve care outcomes. The case-patient explained
that the healthcare provider had provided care for a long time yet there were no commendable
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outcomes. A new provider was recommended to help George meet his expectations, improve the
quality of care and reduce costs. He noted that the new care provider was more knowledgeable as
patient education was provided to improve his care satisfaction. The previous provider was
overwhelmed since she was managing many patients with similar conditions and this was the
reason why she concentrated more on prescriptions than on patient education. Based on George’s
experience, it follows that a population or family problem may impact the quality of care
provided, the costs, and the patient’s safety. According to Wu et al. (2019), An individual or
population problem is likely to affect the quality, care safety, and costs of treating the problem,
and these effects are felt by both the system and the individual.
The case study patient works at an established non-governmental organization (NGO)
that provides education consultants and comprehensive care plans. The NGO catered for his
medical cover and all other medication expenses. This indicates that a comprehensive insurance
cover makes VAP management easier and more affordable. Some patients and populations incur
high costs of managing VAP since they cannot afford comprehensive healthcare cover.
According to Seth (2020), the cost of managing ventilator-associated pneumonia has increased
considerably in the last decade. This has increased the burden of managing the disease, the
safety, and the costs considerations which affect both an individual and the system. As observed
from the case study patient, the factors underlying the increased care costs, reduced safety, and
compromised quality of care include a high number of patients or a large population being
affected by the problem and a lower number of primary care providers. When a large population
is affected by the VAP problem, the risks of developing this disease increase, and this, in turn,
increase care costs for both the system and the individual. These observations are consistent with
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the findings of Seth (2020), and Wu et al. (2019) that showed how a problem affecting a large
population increases care burden and costs.
Nursing Practice Standards and Policies on VAP’s Impact on Care Quality, Safety, and
Healthcare Costs
Each state in America has policies and laws that govern nurse practices to ensure that
nursing professional conduct remains consistent with established standards. For example, the
Nurse Practice Act guides registered nurses to uphold high standards of practice throughout the
profession. One of the ways to improve the quality of care, make healthcare affordable, and
increase safety was by implementing the Affordable Care Act in 2014.
Previous studies have tested the effectiveness of Nursing Practice standards as well as
policies in managing the impacts of VAP on safety, quality, and care costs to the patient and the
system. An example of such studies is that of Tabaeian, Yazdannik, and Abbasi et al. (2018). In
this study, the researchers examined the effectiveness of complying with nursing practice
standards and policies in managing ventilator-associated pneumonia. Using a descriptive crosssectional study design, the researchers assessed 120 nurses in eleven ICU units and investigated
the implementation of policies and practice standards to prevent VAP. Their study findings
indicated that upholding nursing practice standards, and governmental policies reduced the
impact of VAP on quality of care, costs, and care safety.
These standards and policies will guide my actions in addressing quality of care, cost
considerations, and patient safety when managing VAP. In New York State, nursing practice
standards and policies include the Nurse Practice Act which protects patients receiving nursing
care. Other practices include being knowledgeable to provide care, being accountable and
responsible, and maintaining professionalism. I will ensure that my patients are beneficiaries of
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the Affordable Care Act to make their care costs cheap. I will be accountable to ensure that all
my practices concentrate on improving care quality and safety, and reducing costs. I will
implement fully the Nursing Practice Act to ensure that patients’ satisfaction and welfare are met.
Federal, state, and local legislation and policies have effects on the nursing scope of
practice in the context of quality of care, safety, and care cost on individuals and the system. As
a result of these legislations and policies, my case study patient will receive improved care,
despite coming from a rural area due to comprehensive guidelines that will improve care quality,
safety, and cost of managing his VAP condition. The care practice care standards and policies in
my state will not limit the quality of care I offer. Given that I am a registered nurse, I will be able
to provide the necessary care and VAP patient needs.
Strategies to Improve VAP Quality of Care, Safety, and Care Costs
Studies have indicated that strategies such as the evidence-based practices and clinical
support system in VAP care are effective in improving quality, and patient safety, as well as
reducing care costs. For example, an integrative review study by Alecrim et al (2019) indicated
that the application of evidence-based measures reduced the incidents of VAP, and care costs,
and improved patient safety and satisfaction. When care providers adopt these guidelines and
strategies, healthcare institutions report improved quality of care, reduced costs, and improved
patient safety. Alecrim et al. (2019) showed the effectiveness of patient education strategy in
reducing costs, improving care quality, and patient safety. One available source of benchmark
data on strategies for managing VAP patients to increase safety, quality care, and reduced costs
is the study by Mitchell et al. (2019). In this study, the researchers have demonstrated how
patient education and lifestyle modifications can improve care quality, patient safety, and care
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costs. Care providers should utilize effective communication to ensure that patients benefit from
these strategies.
Part 2
Experiences During First 2 Practicum Hours
`
On April 2, 2022, I spent 2 practicum hours with George, who is my case-patient. George
made me learn several strategies as well as nursing practices to effectively manage his condition.
I learned from the patient that his first care provider did not commit herself to provide extensive
education to George. Care outcomes depended solely on his efforts until his primary care
provider was changed. One of the challenges which George reported was a lack of
comprehensive education to manage his VAP condition. I learned other challenges from the
evidence-based practice (EBP) document I reviewed. According to Al-Sayaghi (2021), barriers
and challenges to effective management of VAP include a lack of proper patient education and
lifestyle modifications. The patient mentioned that the first care provider never provided any
education until he was given a second provider.
There were processes and experiences of exploring leadership influence, communication,
collaboration, change management, and policies regarding the VAP problem. Regarding
experience, there were barriers when I was presenting the problem to the patient. He highlighted
that his care outcomes were not improving as he experienced reduced quality of care, and safety.
This challenge made me unable to fully explore my leadership experience. However, the patient
agreed on the presence of a VAP problem was significant and relevant. His experience was
significant because it suggested that an individual problem is likely to affect the quality of care,
health costs, and patient safety. The change management skill that I employed to overcome the
barrier was letting the patient suggest ways that he thinks can improve his care satisfaction. One
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thing I would have done differently would be engaging a different healthcare provider who is
more experienced to help me get relevant support and guidance on an appropriate care plan that
might be useful to the case study patient.
10
References
Alecrim, R. X., Taminato, M., Belasco, A., Longo, M. C. B., Kusahara, D. M., & Fram, D.
(2019). Strategies for preventing ventilator-associated pneumonia: an integrative
review. Revista Brasileira de Enfermagem, 72, 521-530. https://doi.org/10.1590/00347167-2018-0473
Al-Sayaghi, K. M. (2021). Critical care nurses’ compliance and barriers toward ventilatorassociated pneumonia prevention guidelines: a cross-sectional survey. Journal of Taibah
University Medical Sciences, 16(2), 274-282.
https://doi.org/10.1016/j.jtumed.2020.12.001
Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., ÁlvarezRodríguez, J., Lorente, L., … & Agra, Y. (2018). Prevention of ventilator-associated
pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero”
program. Critical care medicine, 46(2), 181.
https://doi.org/10.1097/CCM.0000000000002736
Kharel, S., Bist, A., & Mishra, S. K. (2021). Ventilator-associated pneumonia among ICU
patients in WHO Southeast Asian region: A systematic review. PloS one, 16(3),
e0247832. https://doi.org/10.1371/journal.pone.0247832
Mitchell, B. G., Russo, P. L., Cheng, A. C., Stewardson, A. J., Rosebrock, H., Curtis, S. J., … &
Kiernan, M. (2019). Strategies to reduce non-ventilator-associated hospital-acquired
pneumonia: a systematic review. Infection, Disease & Health, 24(4), 229-239.
https://doi.org/10.1016/j.idh.2019.06.002
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Papazian, L., Klompas, M., & Luyt, C. E. (2020). Ventilator-associated pneumonia in adults: a
narrative review. Intensive Care Medicine, 46(5), 888-906.
https://doi.org/10.1007/s00134-020-05980-0
Seth, S., (December 2020). Ventilator-Associated Pneumonia. MSD and the MSD Manuals.
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences. Retrieved
March 28, 2022, from https://www.msdmanuals.com/professional/pulmonarydisorders/pneumonia/ventilator-associated-pneumonia
Tabaeian, S. M., Yazdannik, A., & Abbasi, S. (2017). Compliance with the standards for the
prevention of ventilator-associated pneumonia by nurses in the intensive care units.
Iranian Journal of Nursing and Midwifery Research, 22(1), 31.
https://doi.org/10.4103/1735-9066.202073
Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk factors of ventilator-associated pneumonia
in critically III patients. Frontiers in pharmacology, 10, 482.
https://doi.org/10.3389/fphar.2019.00482
1
Assessing the Problem
2
Assessing the Problem
Introduction
While ventilation provides oxygenation and better outcomes in patients with breathing
difficulties, it can also escalate the risks of pneumonia. Ventilator-associated pneumonia (VAP)
adds a burden to the care of critically ill patients. The problem is among the leading causes of
morbidities and mortalities in ICU. Nurses play a crucial role in patients’ care. Their role
resonates with the institutional, state, and federal policies to provide patient-centered quality
outcomes. For instance, evidence implies that head elevation is a feasible procedure to minimize
VAP risks. However, nurses’ actions depend on the leadership from the institutional to the state
and federal levels. The administration manages the resources available to support patients’
clinical outcomes. The leadership can seek ways to increase the supply of medically necessary
equipment and beds that facilitate recovery. The state also defines the nursing scope of practice.
Although nurses can have sufficient skills to enable the outcomes, the scope of practice
definition can limit the exercise of their full potential. However, nurses need to liaison with the
other staff and management to improve communication and collaboration to promote safety and
quality outcomes. The leadership skills allow the nurses to be dynamic in ever-changing patients’
needs. Besides, change management is a complex approach that requires strategies such as
training to reduce resistance and compliance with the best practices. This paper will explore the
VAP from the context of the nurses, equipment, leadership, state, and federal guidelines that
promote safety.
Patient Health Problem Relevant to My Practice
Ventilation is among the leading ICU interventions to manage critically ill patients who
require oxygenation. This procedure is medically necessary for patients experiencing breathing
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difficulties, chest pain, and lung dysfunction that compromise breathing patterns. This
intervention’s conditions necessitate asthma, pneumonia, chronic obstructive pulmonary disease,
pulmonary hypertension, and Covid 19. While ventilation is a necessary procedure, it increases
the patients’ susceptibility to VAP. According to Seth (2020), VAP develops within two days, 48
hours among patients with endotracheal intubation. In this problem, the patients experience
aspiration. The aspiration of gram-negative bacteria and bacilli can increase the vulnerability to
the risks of pneumonia. The problem mainly manifests with fever. It can compromise the general
patients’ outcomes, such as worsening oxygenation. Accordingly, VAP can increase the mortality
and morbidity of ICU patients. The problem adds a burden to healthcare spending. For instance,
the pandemic has increased healthcare demands. While many patients require ventilation, VAP
can double the risks of hospital stays, denying other patients from accessing the resources
needed. It also adds the total reimbursement for the treatment. Besides the condition during
admission, VAP adds another state that requires more attention and resources.
Population for the Practicum
This practicum will focus on ICU patients who require intubation within 48 hours in a
local hospital in New York City. The population for this study is the patients manifesting with
labored breathing on admission and diagnosed with conditions such as COPD, pneumonia,
pulmonary hypertension. These patients have impaired lung functions, making ventilation
medically necessary to improve outcomes. Seth (2020) affirms that critically ill patients are more
susceptible to aspiration. These patients are likely to be colonized with gram-negative bacteria in
their oropharynx. When endotracheal intubation is indicated among these patients, the procedure
needs to follow the guidelines that help prevent aspiration. Endotracheal intubation weakens
airway defense which increases the risks of micro-aspiration. This problem can affect intubated
4
patients for up to ten days. VAP is a concern in healthcare since Seth’s (2020) report affects
approximately 27% of the patients on mechanical ventilation. Approaches that solve this issue
can potentially reduce the healthcare burden and spending among critically ill patients.
Relevance of the Problem in My Practice
As a baccalaureate-prepared nurse, my main objective is to offer patient-centered nursing
care to facilitate quality outcomes. The ANA has defined the code of ethics for practice. For
instance, I need to promote safe care promoting patients’ holistic recovery. This strategy is in line
with the providence of nonmaleficence practice. Still, the care needs to benefit the patients.
While ventilation remains the primary intervention in the ICU, it is inherent with challenges such
as VAP. Nothing is more frustrating in practice that implementing an intervention that worsens
the patient’s condition. Poor outcomes affect the patients and healthcare at large, and it also
lowers the nurses’ motivation for quality outcomes. Nurses have a huge workload from the
pressure related to the pandemic and the burden of other diseases. VAP adds a burden, especially
on the resources. Ventilators are among the limited resources in healthcare. When a patient takes
a long time on this resource, it compromises care delivery to other patients who require the same
resource. The limitation can compromise justice as the ethical requirement since the resource is
unavailable for all people. Extended hospital stays also increase the workload. Nursing care can
cause burnout amid the increased needs. So, this problem has an economic, labor force, and
quality burden.
Nursing Actions to Address VAP from the Literature
Evidence has supported that nurses can implement upright positioning as a feasible
intervention to prevent VAP. Farsi, Butler & Zareiyan (2020) performed a Retrospective Clinical
Trial (RCT) to compare the effectiveness of upright positioning versus recumbent positioning in
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minimizing the risks of aspiration among critically ill patients. The results indicated that upright
positioning, which involves the head elevation of between 30 to 45 degrees, can significantly
lower the risks of VAP to up to 50%. This evidence suggests that nurses need to implement
appropriate head elevation of the intubated patients to limit the chances of aspiration. However,
this study has some limitations. For instance, head elevation alone cannot effectively resolve the
issue. Other factors such as patients’ disease severity, clinical status, and colonization by bacteria
and bacilli influence the outcomes. The study fails to acknowledge another confounding variable
that influences the results. While exploring other alternatives using the double-blind clinical trial,
Barani et al. (2018) assessed the VAP among inpatient patients. The study investigated the
effectiveness of the selective oropharynx decontamination approach in eliminating bacteria
colonies. This study seemed to provide quality evidence in addressing the VAP since the process
helped nurses eliminate bacteria using topical gentamicin. However, this study is still
controversial in its application in nursing practice. For instance, the increased prevalence of
antimicrobial-resistant bacteria can be limited. These resistant strains of bacteria do not decrease
exposure to antibiotics. So, the procedure has evidence of reducing VAP with little support on
mortality. From these two pieces of evidence, nurses can mix both methods to improve
outcomes. Besides head elevation, the care needs to decontaminate the oropharynx and entire
digestive system to promote safety.
Reputability of Data
I will know reputable data from unreputable data by evaluating the evidence. I utilize
peer-reviewed research work from reputable databases such as PubMed. This database stocks
articles approved to form the evidence in practice. I also critically appraised the sources by
evaluating the authorship, currency, methodology, ethics, statistical, and clinically significant.
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For instance, systematic reviews and randomized control trials provide primary information with
the highest level of evidence. The two studies used in this work, systematic review, and
randomized control trial, make them reputable for this study.
Nurses in Policymaking and Nursing Theory
The dynamic healthcare needs require nurses to participate in policymaking actively. This
role requires nurses to transform their actions from the bedside to the boardroom. Often, nurses
are the implementors of the policies. Since they understand the patients from the grassroots,
nurses can formulate effective patient-centered policies. Ha, et al. (2019) provided evidence on
the effectiveness of nurses in policymaking. The results indicated that policies championed by
nurses are most effective in promoting patients’ safety. Primarily, this perception happens
because the nurses understand the patients’ conditions holistically. Other studies indicate that
facilities with more nurses in the administration have lower hospital readmission rates.
Watson’s theory of human caring will shape my entire practicum experience. This theory
suggests that patients have diverse needs. Accordingly, nurses play integral roles in meeting the
physical, emotional, and spiritual needs to enhance recovery. The problem of VAP can
potentially lower the quality of care. As a nurse practicing in ICU, I need to abide by
interdisciplinary care to offer patient-centered care which meets the patients’ needs. I also need to
rely on evidence and clinical guidelines to improve collaboration and provide safe ventilation to
prevent readmission.
State Board Nursing Practice Standard
New York State has implemented the hospital bed guidelines. The guideline drafted in
2009 and updated in 2019 provides the institutions’ approach to abide by best bed practices for
safety. The guidelines define different bed categories which are medically necessary. The fixed
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height bed is height nonadjustable with manual leg and head adjustments. The variable height
manually adjusts the height, led, and head. Besides, the electronic ones have automatic height,
leg, and head elevation adjustments. This policy will penalize the facilities which use ordinary
beds, that is, solid furniture, among the patients who require head, leg, or height adjustments.
Overwhelming literature supports this policy. Farsi, Butler & Zareiyan (2020) affirmed that head
elevation of between 30 to 45 degrees lowers the aspiration rates to up to 60% among patients on
ventilators. Hence, this guideline reduces the risks of VAP and improves the quality of care. This
policy informs my decisions and nursing scope of practice. I need to adhere to the stipulated
procedures, such as head elevation among ventilated patients, to reduce the risks of aspiration.
The guidelines allow collaboration with the interdisciplinary team and leadership for safety
outcomes. In providing holistic care, I need to supplement my bedside practice stipulated in the
scope of nursing with critical thinking and collaboration to promote patients’ safety outcomes.
Leadership Strategy
Inclusivity of the nurses in decision making is among the effective leadership strategies
that help in the early detection of the problem, allocation of resources, and facilitating
collaboration in patients’ care. Nurses possess vital experience on patients’ issues that affect
outcomes. They also understand the resources and burden of matching healthcare resources with
the demands. The leadership can integrate approaches that collect the nurses’ views, feedback,
feelings, and responses about different procedures and resources in healthcare. This collaborative
decision-making approach improves the facility’s ability to meet the holistic needs of patients.
Nebbelink and Brewer (2018) researched this leadership strategy and concluded that facilities
that actively include nurses in decision-making have lower hospital readmission rates. This
strategy can also facilitate best bed practices in healthcare. In response, leadership needs to
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respond to the State board bed safety requirements by providing resources that meet the required
standards. For instance, the facility needs to provide beds that facilitate head adjustments in ICU
to prevent VAP. Besides, leadership also needs to listen to the nurses’ concerns on equitable
resource allocation.
Collaboration, Communication, and Change Management
The facility needs to engage all the nurses in decision-making. This approach fosters
effective communication between the patients, providers, and management. One of the best
strategies to facilitate this collaboration is an organization of open discussions through face-toface and virtual meetings. These meetings need to allow the nurses to express their feelings and
views on improving patients’ care environment. The coloration will also enhance the s4eamless
information flow and relationship between the employees and management. Suppose the facility
needs to implement change that facilitates patients’ safety. In that case, the administration needs
to implement training such as simulation that equips the staff with skills to manage the patients’
demands. Evidence suggests that limited knowledge of the change process is the leading cause of
resistance.
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References
Barani, M., Tabatabaei, S. M., Sarani, H., Dahmardeh, A. R., & Keykhah, A. (2018).
Investigating the Effect of Selective Oropharyngeal Decontamination Using Topical
Antibiotics on Oropharyngeal and Tracheal Colonization in Trauma Patients Admitted to
the Intensive Care Units of Zahedan, Iran: A Clinical Trial Study. Medical-Surgical
Nursing Journal, 7(3), e86895. https://doi.org/10.5812/msnj.86895
Farsi, Z., Butler, S., & Zareiyan, A. (2020). The Effect of Semirecumbent and Right Lateral
Positions on the Gastric Residual Volume of Mechanically Ventilated, Critically Ill
Patients. Journal of Nursing Research, 28(4), e108.
https://doi.org/10.1097/jnr.0000000000000377
Ha, D. R., Forte, M. B., Olans, R. D., OYong, K., Olans, R. N., Gluckstein, D. P., … &
McKinnell, J. A. (2019). A multidisciplinary approach to incorporate bedside nurses into
antimicrobial stewardship and infection prevention. The Joint Commission Journal on
Quality and Patient Safety, 45(9), 600-605. https://doi.org/10.1016/j.jcjq.2019.03.003
Nibbelink, C. W., & Brewer, B. B. (2018). Decision-making in nursing practice: An integrative
literature review. Journal of clinical nursing, 27(5-6), 917–928.
https://doi.org/10.1111/jocn.14151
Seth, S., (December 2020). Ventilator-Associated Pneumonia. MSD and the MSD Manuals.
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences. Retrieved
March 28, 2022, from https://www.msdmanuals.com/professional/pulmonarydisorders/pneumonia/ventilator-associated-pneumonia
1
Assessing the Problem: Quality, Safety, and Cost Considerations
Assessing the Problem: Quality, Safety, and Cost Considerations
Introduction
The quality of care is a critical consideration for patients, especially those who reside in
vulnerable urban and rural areas. Healthcare providers focus on the degree of service that
2
increases the chances of desired and positive outcomes. The healthcare quality concept
encompasses care effectiveness that utilizes the best available evidence-based practices to
control major health problems. According to Zhang et al. (2021), providing high-quality
healthcare is followed closely by safety, and reducing costs to make care services affordable,
equitable, efficient, and timely. Healthcare quality, safety, and care cost consideration affect the
management of Ventilator-Associated Pneumonia as evidenced by a case study patient in this
assessment.
Part 1
Previous studies including that of Wu et al. (2019), and Kharel, Bist, and Mishra (2021)
have demonstrated the value of education in managing and improving Ventilator-Associated
Pneumonia care as well as identifying gaps affecting this problem’s care management. These
studies also indicate that inadequate delivery of patient education or not providing education to
patients in totality affects the overall outcomes of a healthcare system. Care help offered by care
providers is integral to VAP treatment compliance as well as lifestyle changes required to
improve patient care. According to Kharel et al. (2021), the inability of physicians and nurses to
equip patients with strategies and information needed to engage in effective VAP management
results in undesired outcomes and poor disease management. Thus, inappropriate management of
Ventilator-Associated Pneumonia leads to disease burden, impacts the quality of care, healthcare
cost considerations, safety, and undesired outcomes.
Quality of Care, Safety, and Cost of Care in Ventilator-Associated Pneumonia
Management
In Ventilator-Associated Pneumonia management, healthcare providers play an essential
role in high care quality which is provided through telehealth technology and programs such as
3
Pay-For-Performance to improve the management of VAP. According to Álvarez-Lerma et al.
(2018), timely and comprehensive patient education for individuals with VAP is critical in
improving the quality of care, reducing costs, and supporting patient safety. In practice,
providing patient education ensures a high-quality care standard while considering the safety of
the patient both at the hospital and at home. Patient education that focuses on routine screening,
active self-management, preventive care, and effective communication forms essential strategies
that guarantee safety and quality in the care of patients with Ventilator-Associated Pneumonia.
As a way to ensure effective patient education as well as improved care and safety for VAP
patients, primary care providers opt for interdisciplinary collaboration that allows them to share
expertise and knowledge and establish a strong interpersonal relationship with the patient and
other physicians to improve patient’s satisfaction. Care cost has been an issue in managing VAP
since untimely interventions may cause ventilator-associated pneumonia to escalate to other
respiratory problems such as Covid-19, pulmonary hypertension, and asthma, and this increases
care costs (Seth, 2020).
Nurses have a critical role in managing care, performance, and care outcomes of VAP.
As such, they aid in implementing working strategies that improve the safety and quality of
patient care. Kharel et al. (2021) examined estimations of VAP prevalence by World Health
Organization and determined that the burden of providing care for this disease will continue to
increase and will not only weigh down nurse practitioners but also increase the cost of care.
Particularly, the authors highlighted that the disease burden will increase to 11.4% by 2030 and
further to 15.8% by 2045 (Kharel et al., 2021). These statistics indicate that instead of the burden
of the VAP problem decreasing, it will continue to increase, and this calls for effective patient
care to manage health costs and increase care outcomes. Evidence-based practices that may
4
improve the management of VAP are providing patients with a comprehensive education during
each of their visits as well as giving them relevant resources that teach them how to manage
Ventilator-Associated Pneumonia. Implementing quality improvement strategies and resources
for patients diagnosed with chronic conditions has impacted significantly care services delivery.
These strategies aid in facilitating appointments, scheduling follow-ups, and helping patients to
manage appropriately their conditions (Papazian et al., 2020). Providers use quality improvement
strategies to determine the best practices that can improve the quality of care and reduce cost.
In practice, an encounter with George, a case study and an ICU patient who require
intubation within 48 hours in a local hospital in New York City, demonstrated how patient,
population, or family problem affects care quality, safety, and care cost to the individual and the
system. George’s experience with getting improved care from his primary care provider as well
as disease management has been below not up to his expectations, and this affects his wellbeing.
Based on the sessions held with him, he explained that his nurse practitioner made little effort in
helping him manage the disease except for prescribing Antipseudomonal Carbapenems drugs.
Notably, the case-patient noted that his primary caregiver did not have any education on lifestyle
changes and other relevant modifications to improve care outcomes. The case-patient explained
that the healthcare provider had provided care for a long time yet there were no commendable
outcomes. A new provider was recommended to help George meet his expectations, improve the
quality of care, and reduce costs. He noted that the new care provider was more knowledgeable
as patient education was provided to improve his care satisfaction. The previous provider was
overwhelmed since she was managing many patients with similar conditions, and this was the
reason why she concentrated more on prescriptions than on patient education. Based on George’s
experience, it follows that a population or family problem may impact the quality of care
5
provided, the costs, and the patient’s safety. According to Wu et al. (2019), An individual or
population problem is likely to affect the quality, care safety, and costs of treating the problem,
and these effects are felt by both the system and the individual.
The case study patient works at an established non-governmental organization (NGO)
that provides education consultants and comprehensive care plans. The NGO catered for his
medical cover and all other medication expenses. This indicates that a comprehensive insurance
cover makes VAP management easier and more affordable. Some patients and populations incur
high costs of managing VAP since they cannot afford comprehensive healthcare cover.
According to Seth (2020), the cost of managing ventilator-associated pneumonia has increased
considerably in the last decade. This has increased the burden of managing the disease, the
safety, and the costs considerations which affect both an individual and the system. As observed
from the case study patient, the factors underlying the increased care costs, reduced safety, and
compromised quality of care include a high number of patients or a large population being
affected by the problem and a lower number of primary care providers. When a large population
is affected by the VAP problem, the risks of developing this disease increase, and this, in turn,
increase care costs for both the system and the individual. These observations are consistent with
the findings of Seth (2020), and Wu et al. (2019) that showed how a problem affecting a large
population increases care burden and costs.
Nursing Practice Standards and Policies on VAP’s Impact on Care Quality, Safety, and
Healthcare Costs
Each state in America has policies and laws that govern nurse practices to ensure that
nursing professional conduct remains consistent with established standards. For example, the
Nurse Practice Act guides registered nurses to uphold high standards of practice throughout the
6
profession. One of the ways to improve the quality of care, make healthcare affordable, and
increase safety was by implementing the Affordable Care Act in 2014.
Previous studies have tested the effectiveness of Nursing Practice standards as well as
policies in managing the impacts of VAP on safety, quality, and care costs to the patient and the
system. An example of such studies is that of Tabaeian, Yazdannik, and Abbasi et al. (2018). In
this study, the researchers examined the effectiveness of complying with nursing practice
standards and policies in managing ventilator-associated pneumonia. Using a descriptive crosssectional study design, the researchers assessed 120 nurses in eleven ICU units and investigated
the implementation of policies and practice standards to prevent VAP. Their study findings
indicated that upholding nursing practice standards, and governmental policies reduced the
impact of VAP on quality of care, costs, and care safety.
These standards and policies will guide my actions in addressing quality of care, cost
considerations, and patient safety when managing VAP. In New York State, nursing practice
standards and policies include the Nurse Practice Act which protects patients receiving nursing
care. Other practices include being knowledgeable to provide care, being accountable and
responsible, and maintaining professionalism. I will ensure that my patients are beneficiaries of
the Affordable Care Act to make their care costs cheap. I will be accountable to ensure that all
my practices concentrate on improving care quality and safety, and reducing costs. I will
implement fully the Nursing Practice Act to ensure that patients’ satisfaction and welfare are met.
Federal, state, and local legislation and policies have effects on the nursing scope of
practice in the context of quality of care, safety, and care cost on individuals and the system. As
a result of these legislations and policies, my case study patient will receive improved care,
despite coming from a rural area due to comprehensive guidelines that will improve care quality,
7
safety, and cost of managing his VAP condition. The care practice care standards and policies in
my state will not limit the quality of care I offer. Given that I am a registered nurse, I will be able
to provide the necessary care and VAP patient needs.
Strategies to Improve VAP Quality of Care, Safety, and Care Costs
Studies have indicated that strategies such as the evidence-based practices and clinical
support system in VAP care are effective in improving quality, and patient safety, as well as
reducing care costs. For example, an integrative review study by Alecrim et al (2019) indicated
that the application of evidence-based measures reduced the incidents of VAP, and care costs,
and improved patient safety and satisfaction. When care providers adopt these guidelines and
strategies, healthcare institutions report improved quality of care, reduced costs, and improved
patient safety. Alecrim et al. (2019) showed the effectiveness of patient education strategy in
reducing costs, improving care quality, and patient safety. One available source of benchmark
data on strategies for managing VAP patients to increase safety, quality care, and reduced costs
is the study by Mitchell et al. (2019). In this study, the researchers have demonstrated how
patient education and lifestyle modifications can improve care quality, patient safety, and care
costs. Care providers should utilize effective communication to ensure that patients benefit from
these strategies.
8
References
Alecrim, R. X., Taminato, M., Belasco, A., Longo, M. C. B., Kusahara, D. M., & Fram, D.
(2019). Strategies for preventing ventilator-associated pneumonia: an integrative
review. Revista Brasileira de Enfermagem, 72, 521-530. https://doi.org/10.1590/00347167-2018-0473
Al-Sayaghi, K. M. (2021). Critical care nurses’ compliance and barriers toward ventilatorassociated pneumonia prevention guidelines: a cross-sectional survey. Journal of Taibah
9
University Medical Sciences, 16(2), 274-282.
https://doi.org/10.1016/j.jtumed.2020.12.001
Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., ÁlvarezRodríguez, J., Lorente, L., … & Agra, Y. (2018). Prevention of ventilator-associated
pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero”
program. Critical care medicine, 46(2), 181.
https://doi.org/10.1097/CCM.0000000000002736
Kharel, S., Bist, A., & Mishra, S. K. (2021). Ventilator-associated pneumonia among ICU
patients in WHO Southeast Asian region: A systematic review. PloS one, 16(3),
e0247832. https://doi.org/10.1371/journal.pone.0247832
Mitchell, B. G., Russo, P. L., Cheng, A. C., Stewardson, A. J., Rosebrock, H., Curtis, S. J., … &
Kiernan, M. (2019). Strategies to reduce non-ventilator-associated hospital-acquired
pneumonia: a systematic review. Infection, Disease & Health, 24(4), 229-239.
https://doi.org/10.1016/j.idh.2019.06.002
Papazian, L., Klompas, M., & Luyt, C. E. (2020). Ventilator-associated pneumonia in adults: a
narrative review. Intensive Care Medicine, 46(5), 888-906.
https://doi.org/10.1007/s00134-020-05980-0
Seth, S., (December 2020). Ventilator-Associated Pneumonia. MSD and the MSD Manuals.
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences. Retrieved
March 28, 2022, from https://www.msdmanuals.com/professional/pulmonarydisorders/pneumonia/ventilator-associated-pneumonia
Tabaeian, S. M., Yazdannik, A., & Abbasi, S. (2017). Compliance with the standards for the
prevention of ventilator-associated pneumonia by nurses in the intensive care units.
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Iranian Journal of Nursing and Midwifery Research, 22(1), 31.
https://doi.org/10.4103/1735-9066.202073
Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk factors of ventilator-associated pneumonia
in critically III patients. Frontiers in pharmacology, 10, 482.
https://doi.org/10.3389/fphar.2019.00482
1
Assessing the Problem: Technology, Care Coordination, and Community Resources
2
Introduction
The disparities in healthcare in the country have adversely affected women and babies of
color. These populations are more likely to suffer from poor pregnancy outcomes. The March of
Dimes (2021) indicates that women of color are more than three times more likely to die from
poor pregnancy outcomes than Whites. This evidence further suggests that one in two women
from this group are likely to give birth prematurely. These issues escalate to the children’s health.
Notably, these children are in double danger of infant mortality rates. The root cause of this
problem ranges from social, cultural, and national. For instance, institutional racism can
propagate care delivery based on the patients’ backgrounds. Although the country has achieved
significant healthcare milestones for all, essential services like timely maternal care are
privileged to those who can afford it. Baer et al. (2019) suggested that African American mothers
are more likely to receive late antenatal care. This gap indicates that healthcare will lack
effective intervention to address pregnancy complications earlier. Other factors like the
distribution of resources discriminate against people from low-income regions. Mothers from
vulnerable groups do not have ready access to antenatal care. Although Medicaid and CHIP have
empowered maternal and child health, some of the population cannot afford the increased costs
attributed to care. No feasible policies have addressed the issue holistically. As the demands for
care rise, this population will face the double burden of poor healthcare access. This paper will
focus on how technology, coordination of care, and community resources can potentially
alleviate the problem of healthcare disparities among women of color.
Impact of Healthcare Technology on Population Problem
Healthcare technology has revolutionized care delivery, especially among the
underserved population. The implementation of Electronic Health Records was among the
3
leading technological initiatives that improved care delivery. This move has also empowered
more sophisticated advancements such as self-care programs which have allowed patients to take
the lead in their care. Recently, telehealth has proven to bridge the gaps in access to care. With
these approaches, patients can access healthcare services regardless of the region. These changes
mean that providers can virtually interact with the patients and families, reducing the costs
attributed to transport (Snoswell et al., 2020). Now, the patients from the low-income regions do
not need to worry about traveling to the healthcare facility. The changes have brought healthcare
near the people who want it the most. Another platform is wearable devices to monitor patients’
conditions and performance. These alternatives reduce the hospital visits since the patients can
monitor parameters like heart pressure at home. Besides, healthcare cannot underestimate the
role of social media in health education. With a single Facebook post, the facility can reach
millions of users, which has improved health literacy. All these methods can potentially solve the
gap in access toga among women of color.
Advantages and Disadvantages of Healthcare Technologies
Healthcare technologies have brought healthcare to the hands of the patients-meaning
that patients have the liberty to choose what they want and the services they desire. For instance,
telehealth has revolutionized the patient-provider relationship. The family can now complete the
healthcare consultations with the video conference. This issue has also helped healthcare in
demand management. The hospitals have prioritized what they provide emergency care.
Telehealth can help healthcare minimize unnecessary hospital visits and focus o priority cases.
Another advantage is the self-care programs, which have empowered the patients to make wiser
decisions about their health. However, these advancements have some challenges. For instance,
low-income regions can have slow internet connections. This issue can create another barrier to
4
access to healthcare services, which is only limited to technologically literate people. These
options cannot feasibly work among the low-literacy population, making up a significant portion
of the underserved.
Consistency of Technology in Nursing Practice
It is not surprising to note that the wide-scale application of this technology will face
challenges. I have indicated that advancement in technology comes with other costs. As much as
telehealth can potentially reduce transport costs, other expenses such as installation are a bother.
While trying to solve the gaps in access to care, I noted that technology could favor the literate
and affluent people, failing to address issues among the vulnerable. Technologies such as
wearable devices are excellent in promoting self-care programs. However, healthcare cannot
afford to offer all the patients from underserved populations these tools. This gap will suggest
that the care will only be available to those who can afford and understand the technology. So, I
consider these options potentially helpful, yet more research and investment will help bridge the
gaps for wide-scale application.
Potential Barriers, Costs, and How these technologies Apply to the Problem
The considerable barrier to technological advancement is disparities in literacy levels.
While healthcare strives to empower the population to live healthy, it cannot solve the societal
issues of low literacy. It is also time-consuming and costly to implement education for widescale technology utilization. Telehealth, self-care, and wearable devices face installation costs
and the internet barrier. However, these technologies can apply specifically to this problem to
bridge the gaps in care disparity. Jimah et al. (2021) researched the effectiveness of Two Happy
Hearts, the CHV’s coordinated technology for the mind-body program. This technology can
5
monitor personal health and enhance stress management. The research indicated that the
technology effectively improves maternal health, especially for underserved populations.
Care Coordination and Community Resources in Addressing the Problem
Literature Evidence of Benefits and Limitations of Care Coordination and Community
Resources
Community resources bring care closer to the population who need it the most, the
vulnerable and underserved. California has implemented the Nurse-Family Partnership Program.
It is a free, evidence-based, and voluntary service for low-income first-time mothers. The
program provides care at the doorstep until the child attains two years. Evidence suggests that the
program improves child health and development, improves pregnancy outcomes, and enhances
mothers’ economic stability. Besides, CMS launched the care coordination program. This
program is similar to Nursing Home Visits in California, yet it operates countrywide. It connects
mothers to required resources, including educational materials, mental health, support networks,
and organized referral programs. These coordinated services target the at-risk population. It has
helped build capacity and resilience for mothers in underserved regions (Wachino & Macrae
n.d.). However, Danielsen et al. (2018) found that home visits are ineffective due to
compromised safety of a nurse, limited privacy, and increased destruction.
Consistency of the Information in Nursing Practice
Home visiting programs have helped our facility to reach unreachable mothers. Through
the surveillance system, the facility can trace at-risk mothers. After training, the facility
coordinates the home visits to access the mothers with healthcare services such as screening,
healthcare education, and other referral programs. The program has empowered the vulnerable to
6
have hope in raining healthy children. So, these coordinated services and community resources
resonate with what I observe in practice.
Barriers to the Use of Care Coordination and Community Resources
I have noted that conducting home visits has a significant limitation on time and cost. The
increased demands mean that healthcare serve from staff shortage, implying that a few nurses
and providers will be available to conduct home visits and coordinate care with CHVs. Also,
home visit programs are a long-term goal meaning that one-time visits alone cannot bring
change. However, healthcare has limited capacity to provide long-term care to many patients.
Other resources like transport increase budgetary spending. So, the programs can only serve
within a limited capacity, meaning they will not reach many vulnerable communities.
Policies on Healthcare Technologies, Care Coordination, and Community Resources
HIPAA Compliance Policies require that parties dealing with protected health
information ensure privacy, confidentiality, and safety. Privacy and confidentiality are
significant issues when declining with telehealth and wearable devices. HIPAA has stipulated
that the technology vendor needs to implement structures that prevent access to PHI by an
unauthorized person. This policy requires providers to adhere to confidential and secured data
sharing while interacting with patients via telehealth. Besides, Medicaid provides States with the
liberty to define the home visiting program’s services. However, the agency stipulated that it only
covers specified services-meaning that States seeking comprehensive services outside the
classified groups need to seek alternative financing. The agency further affirms that it only caters
to services that meet requirements such as case management and preventive and rehabilitative
ones.
7
How Policies will Guide My Actions for Care Quality, Cost, and Patients’ Safety and
Implications of Policies in Scope of Practice
I will strictly utilize the technologies that are HIPAA compliant. This action helps me to
protect patients’ safety and confidentiality. So, the priority action as a nurse is not only to ensure
that patients access the feasible technology but also to protect their data from unauthorized
access. Besides, costs of care are an issue in-home visit programs. Although I seek to help my
patients achieve better health, practicing the services not covered by Medicaid is not feasible.
Many of these patients come from low-income region-meaning that out-of-pocket spending can
be troublesome. I will only stick to the services defined by the State and Medicaid, including
preventative, rehabilitative, and case management.
How Nursing Ethics Will Guide My Decision
The fundamental ethical practice is non-maleficence. This principle makes me adhere to
the safety procedures that will produce outcomes that promote the well-being of the patients.
Harm to the patients comes in many ways. For instance, managing telehealth or family meeting
in the presence of a family member not authorized as the significant other can potentially cause
harm. So, I will always ensure that the patient is comfortable and has no destructions in attending
the session. However, not harming alone cannot help society. I need to implement the activities
that will help the patient access care and improve outcomes according to the beneficence
principle. It is also necessary for me to recommend technology that is affordable and accessible
for justice. Even if the technology is effective, it lacks the essence when the patients have no
knowledge to utilize it. The uttermost decision is to help the patients make the decision rather
than dictating what they need. This approach will allow me to abide by the autonomy of the
patients.
8
9
References
Baer, R. J., Altman, M. R., Oltman, S. P., Ryckman, K. K., Chambers, C. D., Rand, L., &
Jelliffe-Pawlowski, L. L. (2019). Maternal factors influencing late entry into prenatal
care: a stratified analysis by race or ethnicity and insurance status. The journal of
maternal-fetal & neonatal medicine: the official journal of the European Association of
Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the
International Society of Perinatal Obstetricians, 32(20), 3336–3342.
https://doi.org/10.1080/14767058.2018.1463366
Danielsen, B. V., Sand, A. M., Rosland, J. H., & Førland, O. (2018). A qualitative study is the
experiences and challenges of home care nurses and general practitioners in home-based
palliative care. BMC palliative care, 17(1), 95. https://doi.org/10.1186/s12904-018-03500
Jimah, T., Borg, H., Kehoe, P., Pimentel, P., Turner, A., Labbaf, S., Asgari Mehrabadi, M.,
Rahmani, A. M., Dutt, N., & Guo, Y. (2021). A Technology-Based Pregnancy Health and
Wellness Intervention (Two Happy Hearts): Case Study. JMIR formative research, 5(11),
e30991. https://doi.org/10.2196/30991
March of Dimes.Org (2021). Health crisis impacting babies and women of color. Retrieved on
May 19, 2022, from https://www.marchofdimes.org/mission/health-disparities.aspx
Snoswell, C. L., Taylor, M. L., Comans, T. A., Smith, A. C., Gray, L. C., & Caffery, L. J.
(2020). Determining if Telehealth Can Reduce Health System Costs: Scoping
Review. Journal of medical Internet research, 22(10), e17298.
https://doi.org/10.2196/17298
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Wachino, V., & Macrae, J., (n.d.). Coverage of Maternal, Infant, and Early Childhood Home
Visiting Services. Center for Medicaid & CHIP Services, Health Resources and Services
Administration. https://www.medicaid.gov/federal-policy-guidance/downloads/cib-0302-16.pdf

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