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Capella 4900 Assessment 4

Capella 4900 Assessment 4

Capella 4900 Assessment 4 Patient, Family, or Population Health Problem Solution

Student Name

Capella University

NURS-FPX 4900 Capstone Project for Nursing

Prof. Name


Patient, Family, or Population Problem Solution

This paper is based on the identified health problem of a patient named John who is 45 years old male suffering from COPD and requires a health problem solution. John, being an ex-smoker has damaged his lungs to a significant extent and his health condition is worsening day by day with severe exacerbations. Therefore, it is integral to develop a health problem solution for John and other patients like him as it is a relevant and common condition to our professional practice.

Role of Leadership and Change Management in Addressing COPD

In any professional setup, leadership and change management are essential to bring positive changes and outcomes. Likewise, in healthcare systems where the patient’s quality of life is deteriorating and hospital readmission or revisit rates are increasing, there is a dire need for leadership and change management. Leadership and change management are important for developing a clear vision, the expected goals, and the outcomes of COPD treatment. Leaders can foster a collaborative culture where all healthcare providers can participate in providing effective care treatment to COPD patients such as pulmonologists, nurses, pharmacists, and respiratory therapists. Change management such as implementing changes in clinical practices, guidelines, and health technologies also plays a vital role in addressing COPD (Wanser & Luckel, 2021).

In the case of John, leadership and change management helped massively in addressing his condition of COPD. The transformational leadership strategy helped physicians and nurses to make informed and wise decisions in worsening cases of COPD in John’s case, which led to a systematic delivery of care treatments. Furthermore, nurses were confident in acquiring leadership roles in this strategy and improved their working with other health professionals including physicians and pharmacists. 

Capella 4900 Assessment 4

The change management strategies such as establishing a clear vision, building effective communication, and training and support sessions for health providers played a convincing role in the development of intervention best suited for John’s health condition. The change management strategies influenced the development of the intervention as these strategies prioritized the systems that were crucially needed and could potentially enhance the patient’s condition of COPD. For example, the IT department participated to include its services in better delivery of care treatment (Moussa et al., 2019). 

Nursing ethics guided nurses in the development of an intervention for COPD patients like John. These nursing principles are autonomy, beneficence, nonmaleficence, justice, and confidentiality (Haddad & Geiger, 2022). Nurses were aware that patients have the right of making a decision about their own intervention which led them to collaborate with patients and develop an intervention that best suited them and their health needs. Furthermore, nurses were benign and compassionate in developing patient-centered health interventions which focused on their ease and well-being. Nurses were aware of the principles of confidentiality as they need to abide by the principles of the HIPAA Act. Therefore, they were conscious of respecting patients’ confidentiality and privacy and overall followed the nursing ethics for better interventions. 

Communication and Collaboration Strategies to Improve COPD Outcomes

For effective and desired outcomes, it is necessary to implement best-practice communication and collaboration strategies in healthcare systems. Some of these communication and collaboration strategies which can improve COPD outcomes in the patients like John are active listening, goal setting, and patient-centered care.  Healthcare professionals should take the time to listen to patients’ concerns, experiences, complaints, and questions with great interest and eagerness. This will create a supportive and empathetic environment where the patient will feel heard, valued, and comfortable sharing his concerns about COPD and overall health condition. Healthcare professionals should engage with patients in establishing goals that are realistic and achievable. These goals can be adherence to medication, improving physical activity, regular monitoring of symptoms, and smoking prevention.

By adopting the patient-centered care approach, healthcare providers are able to consider the individual and customized needs & preferences of patients. This will create an engaging bond between patients and healthcare providers, further facilitating the care treatment. Furthermore, using a common and simple language to ensure that the patient is able to understand medical information and instruction is another communication strategy that will improve the outcomes of care treatment. As the patient can grasp information only in a language he is familiar with; therefore, clear communication will enable John to follow guides and education on medication and treatment and improve the outcomes (Noordman et al., 2020).  

Capella 4900 Assessment 4

These communication and collaboration strategies can effectively improve the COPD care treatment outcomes in John which will ultimately improve his quality of life and safety. Besides these strategies, it is pivotal to obtain input from the patients as it can help health professionals to create treatment plans tailored to patients’ needs, preferences, and values. Additionally, the benefits of obtaining input from patients through effective collaboration with patients,  include improved chances of treatment adherence as their valuable participation in providing information will foster a sense of ownership and empowerment which will likely increase treatment adherence. Moreover, hospital professionals can identify and address their concerns and barriers permitting patient-centered care and other solutions based on their concerns. 

Role of State Board Nursing Practice Standards & Governmental Policies 

The American Nursing Association has provided standards of professional performance and these standards have guided the development of the proposed intervention. These guiding standards are assessment, diagnosis, outcome identification, planning, implementation, and evaluation (American Nurses Association, 2015). The nurses following these standards, in collaboration with other health providers, proposed the intervention plan for John considering the outcomes that are identified in the standard practice step of outcome identification. Once the outcomes are identified, the health professionals developed an intervention for John’s condition COPD.

  The Affordable Care Act (ACA) facilitated the development of intervention by providing the guiding principles for health insurers with respect to people like John who suffer from chronic conditions or pre-existing conditions like COPD. The ACA enhanced health protection and made it illegal for health insurance companies to deny coverage or charge higher premiums on the basis of a patient’s medical history. This provision of ACA helped in developing an intervention for John as he will not have to worry about health access and medication (Cleveland et al., 2019). These nursing standards and ACA policy have been effective in improving outcomes in patients as they are guiding tools and facilitating factors that have the potential to improve the symptoms and outcomes of care treatment. 

Proposed Intervention, Quality of Care, Patient Safety, & Cost

The proposed intervention for John is multifaceted. It is an amalgamation of telehealth and remote monitoring services along with self-management education on COPD. Telehealth and remote monitoring is the utilization of technology for the provision of healthcare services and monitoring care treatment and health status of patients remotely. This will improve the quality of care by enhancing access to care, particularly for patients like John who find it difficult to travel to hospitals for clinical visits. Moreover, self-management education through telehealth will improve John’s knowledge of his condition and help him manage it through guidelines and protocols taught by health professionals. This proposed intervention will enable nurses and other health providers to detect any abnormalities or symptoms worsening through remote monitoring, enhancing the quality of care provided to patients (Janjua et al., 2021).

Telehealth-based treatment and self-management enhance patient safety by reducing the exposure of patients to infectious diseases in times of disease outbreaks as the care is provided remotely. Moreover, medical errors can be avoided by remote consultations and electronic prescribing systems as opposed to handwritten prescriptions where there are chances of misinterpreting the prescriptions. Remote monitoring and telehealth-based SMS reminders can create continuity of care while promoting medication and treatment adherence, further improving patient safety for John (Snoswell et al., 2021).

Capella 4900 Assessment 4

The proposed intervention plays a vital role in reducing costs as the patient gets treatment at home, and the costs incurred to John due to commute will be saved. Furthermore, hospital readmission rates will be reduced as the ongoing treatment will prevent future emergencies and hospital management can further optimize resource allocation when telehealth is implemented.  Chronic disease management will be cost-effective through the proposed intervention through remote monitoring and education, better adherence, and early detection of health issues. This will result in reduced costs to both the patient and the healthcare systems. (Fox et al., 2022).  

The relevant benchmark data include St George’s Respiratory Questionnaires (SGRQ) which depicts the quality of life measures in COPD. A variation in the total score for SGRQ that shows a clinically significant difference is 4 units. The patient’s quality of care can be evaluated by utilizing this SGRQ in which the patient will answer the questions present in the questionnaire about his health condition and wellness. The scoring range is 0-100, with the 0 value showing efficacious care while 100 shows poor health status (Choi et al., 2019).

Technology, Care Coordination, and Community Resources Use

Health information technologies (HIT), care coordination, and utilization of community resources are helpful in addressing John’s COPD condition. HIT like electronic health records (EHR), telehealth, and telemedicine are effective and innovative strategies to treat and manage chronic conditions like COPD. These digital versions of patient medical records are easily accessible to use among health professionals and promote immediate therapy as there is no hassle of paper-based medical records. Moreover, telehealth and telemedicine facilitate the delivery of healthcare services remotely. Thus, COPD will be managed effectively, and desired treatment can be provided through applications installed on phones or web-based portals (Ding et al., 2019).

 Chronic disease like COPD requires coordinated care with the help of interprofessional collaboration. In COPD, pulmonologists, respiratory therapists, nurses, pharmacists, and health technologists all should coordinate effectively in providing care treatment to patients so as to minimize errors and prevent missing any important care treatment. This care coordination is necessary for shared-decision making between healthcare professionals and COPD patients. Moreover, care coordination can help optimize medication management in COPD patients and ensure that the patient has not missed any dose which is essential for the effective management of COPD (Atwood et al., 2022).

The utilization of community resources provided by the American Lung Organization, CDC, and COPD Foundation can be helpful in guiding nurses and other health professionals to deliver authentic and correct care treatments based on the protocols and guidelines. Guidelines on symptoms, management strategies, and treatment agendas are important to follow for all health professionals so that patients’ safety and quality of life are not compromised 


The primary focus of this assessment is to develop and propose an intervention for John’s health condition i.e. COPD. First, the leadership and change management role is seen in addressing COPD, and their impact on the proposed intervention is evaluated. Furthermore, communication and collaboration strategies with their impact on the proposed intervention are discussed. American Nursing Board standards for nursing practice guidance on developing intervention are used along with the ACA policy. Moreover, the impact of the proposed intervention with respect to quality of care, patient safety, and cost is evaluated. Lastly, the ways technology, care coordination, and community resource utilization can be done in managing COPD are found. 


American Nurses Association. (2015). Nursing: Scope and Standards of Practice. 

Atwood, C. E., Bhutani, M., Ospina, M. B., Rowe, B. H., Leigh, R., Deuchar, L., Faris, P., Michas, M., Mrklas, K. J., Graham, J., Aceron, R., Damant, R., Green, L., Hirani, N., Longard, K., Meyer, V., Mitchell, P., Tsai, W., Walker, B., & Stickland, M. K. (2022). Optimizing COPD acute care patient outcomes using a standardized transition bundle and care coordinator: A randomized clinical trial. Chest, 162(2), 321–330. 

Choi, J. Y., Yoon, H. K., Shin, K.-C., Park, S.-Y., Lee, C. Y., Ra, S. W., Jung, K. S., Yoo, K. H., Lee, C.-H., & Rhee, C. K. (2019). CAT Score and SGRQ Definitions of Chronic Bronchitis as an Alternative to the Classical Definition. International Journal of Chronic Obstructive Pulmonary Disease, 14, 3043–3052. 

Cleveland, K., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses OJIN: The online journal of issues in nursing 

Ding, H., Fatehi, F., Maiorana, A., Bashi, N., Hu, W., & Edwards, I. (2019). Digital health for COPD care: The current state of play. Journal of Thoracic Disease, 11(17), S2210–S2220. 

Fox, L., Heiden, E., Chauhan, M. A. J., Longstaff, J. M., Balls, L., De Vos, R., Neville, D. M., Jones, T. L., Leung, A. W., Morrison, L., Rupani, H., Brown, T. P., Stores, R., & Chauhan, A. J. (2022). Evaluation of telehealth support in an integrated respiratory clinic. Npj Primary Care Respiratory Medicine, 32(1). 

Capella 4900 Assessment 4

Haddad, L. M., & Geiger, R. A. (2022). Nursing ethical considerations. National Library of Medicine. 

Janjua, S., Carter, D., Threapleton, C., Prigmore, S., & Disler, R. (2021). Telehealth interventions: Remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews. 

Moussa, L., Garcia-Cardenas, V., & Benrimoj, S. I. (2019). Change facilitation strategies used in the implementation of innovations in healthcare practice: A systematic review. Journal of Change Management, 19(4), 1–19. 

Noordman, J., Schulze, L., Roodbeen, R., Boland, G., van Vliet, L. M., van den Muijsenbergh, M., & van Dulmen, S. (2020). Instrumental and affective communication with patients with limited health literacy in the palliative phase of cancer or COPD. BMC Palliative Care, 19(1). 

Snoswell, C. L., Stringer, H., Taylor, M. L., Caffery, L. J., & Smith, A. C. (2021). An overview of the effect of telehealth on mortality: A systematic review of meta-analyses. Journal of Telemedicine and Telecare, 1357633X2110237.×211023700 

Capella 4900 Assessment 4