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NURS FPX 6030 Assessment 3 Intervention Plan Design

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    NURS FPX 6030 Assessment 3 Intervention Plan Design

    Student Name

    Capella University

    NURS-FPX 6030 MSN Practicum and Capstone

    Prof. Name


    Intervention Plan Design

    This assessment presents an interventional plan based on the PICO(T) statement developed for patients discharged from Manatee Memorial Hospital in Bradenton, Florida. Our PICO(T) approach compares the implementation of a comprehensive and personalized post-discharge education program with the provision of basic discharge instruction in post-cardiac catheterization patients. The desired outcomes from this research are reduced 30-day hospital readmission rates and improved patient outcomes within a year of implementation. 

    Intervention Plan Components 

    The intervention plan for improving post-discharge outcomes is based on providing comprehensive and individualized discharge education. The major components of this plan include customized educational programs and telehealth services. 

    Customized Educational Plans:

    The first step of this component is to perform patients’ assessments and profiling, where we will understand and evaluate patients’ health literacy levels, their learning needs and preferences, and other socio-cultural factors that may impede the learning and self-management process. This step is essential to tailoring our educational program, integrating patient-centeredness, and leading to better patient governance (Krook et al., 2020). After the assessment, individualized discharge instructions will be developed, considering patients’ cultural beliefs, health needs, language preferences, and health practices. A holistic training of procedural details, medication management, and dietary and physical activity advice is essential. This component of the intervention plan will result in patient engagement in their healthcare process and shared decision-making, thus enabling patients to adhere to the instructions. Ultimately improving health conditions and reducing readmission rates. 

    Telehealth Services:

    Another component is integrating technological communication methods and digital health services for effective discharge education and post-discharge adherence to the instructions. Since the advent of telemedicine, a significant improvement in achieving quintuple aims has been observed. This includes improvement in patient experiences, cost-effectiveness, enhanced health outcomes, healthcare equity, and well-being of the providers (Chen et al., 2023). In our intervention plan, telehealth services can be used for post-discharge patient education, monitoring, and measuring outcomes. A multimodal education delivery approach can be used, whereby various technological tools, such as audiovisual, remote-monitoring devices, and communication tools, can be utilized for delivering important information and addressing patients’ concerns.

    This component is essential for our intervention plan so patients can be monitored and constantly guided for treatment adherence and self-management of health issues, eventually reducing hospital visits and readmission rates. The criteria to assess the plan’s success are improved patient outcomes, enhanced knowledge about self-care practices, patients’ adherence to the care plan, and the rate of 30-day hospital readmissions. The tools for evaluating are remote monitoring, patient feedback, and hospital databases for the number of hospital visits and admissions. 

    Cultural Needs and Characteristics of Population and Care Setting 

    The target population for this capstone project is the patients undergoing cardiac catheterization at Manatee Memorial Hospital in Bradenton, Florida. Generally, the cultural needs of the patient population significantly influence the development of an intervention care plan as it assists the providers in developing personalized care based on individual needs and preferences, considering the social and cultural barriers. This aspect of care is vital for prioritizing public interest while providing healthcare services (Getha-Taylor et al., 2020). The statistics presented by the U.S. Census Bureau reveal that the total population in Bradenton city is 56,961, belonging to different ethnic and racial groups.

    The population comprises 74.3% White Americans, Black or African alone constitute 14.8%, Hispanic/Latino is 21.4%, and the rest are in traces (U.S. Census Bureau, n.d.). This diverse population advocates the need for a culturally competent intervention plan where the customized educational plans, as a component of our intervention, focus on respecting patients’ language preferences, cultural beliefs, and health practices. This will further ensure patients’ inclusivity and effectiveness of care.

    NURS FPX 6030 Assessment 3 Intervention Plan Design

    Moreover, customized communication strategies in multimodal educational delivery will ensure patients are fully engaged and involved in the interventional plan using easy-to-understand language, catering to their literacy levels and language differences. In the organizational setting, the corporate culture of Manatee Memorial Hospital (MMH) plays a crucial role in developing our intervention plan. Cultural awareness among healthcare professionals about their own and patients’ cultural beliefs facilitates communication between patients and providers (Kaihlanen et al., 2019).

    Within the MMH care setting, the established cultural competence training programs for healthcare professionals impact the development of our intervention plan, whereby the objectives are to improve interprofessional teamwork, patient engagement, and patient-centered discharge planning and education for post-cath patients. The underlying assumption is the importance of culturally competent care as the studies support the development of culturally tailored interventions for the patients to observe effective health outcomes and patient satisfaction. Moreover, studies also promote the integration of cultural factors in discharge planning and education to reduce hospital readmission rates (Handtke et al., 2019; Santacroce, 2019). 

    Theoretical Foundations 

    Of several nursing theories, Dorothea Orem’s Self-Care Theory is primarily applicable in designing our intervention plan. The theory’s strength is that it accentuates patients’ role in managing their health conditions. Comprehensive discharge education for post-operative cardiac patients is aligned with the goal of this theory to encourage patient engagement in their recovery through appropriate self-care practices. A study by Khademian et al. (2020) concluded that education on self-care using this theory showed positive patient outcomes and improved quality of life for hypertensive patients.

    Thus, the theory can be effectively used for post-surgery patients. Using this theory, healthcare providers can develop a comprehensive discharge education that includes information about medication plan compliance and lifestyle modifications. One of the weaknesses of this model is that it assumes patients’ motivation and ability to adhere to the treatment plans, which may not match the reality, and several factors may impede, such as education levels and socio-cultural and economic barriers. 

    NURS FPX 6030 Assessment 3 Intervention Plan Design

    Secondly, motivational interviewing (MI), as a strategy from other disciplines, can influence patients’ behavioral changes (Bischof et al., 2021). In discharge education for post-cardiac catheterization patients, this strategy enormously helps healthcare providers evaluate patients’ readiness for the change, adhere to the treatment plan, and address any uncertainties. However, implementing MI is time-consuming to engross patients in significant conversations and manage potential resistance.

    Lastly, the use of telecommunication methods like video conferencing and remote monitoring devices will impact the design of our intervention plan, where one of the components is to add telehealth services. This assists healthcare providers in keeping patients’ records and monitoring their progress after the surgery, along with constantly helping them through the self-management process, improving patient outcomes (Chen et al., 2023). Conversely, the effectiveness of telehealth depends on the user’s accessibility and comfort. Internet connectivity can become another significant obstacle in the care coordination process.  

    Justification Using Credible Evidence 

    • Orem’s Self-Care Theory can be justified by the study, which concluded that patients with hypertension showed positive outcomes because of their training in self-management practices (Khademian et al., 2020). Our interventional design of comprehensive discharge education primarily fits this theory of encouraging self-care practices to improve adherence and reduce hospital readmission rates. 
    • Since our comprehensive education program is based on customized education plans, motivational interviewing is justified as it focuses on patient-centered instructions instead of providing primary and general discharge instructions for the patients (YU et al., 2019). 
    • As one of the components in our intervention plan is based on telehealth services, a study by Chen et al. (2023) reflects on the effectiveness of telehealth and telecommunication in enhancing patient education and treatment adherence, minimizing the risks of hospitalization. 

    Stakeholders, Policy, and Regulations 

    Our intervention plan is primarily focused on the needs of the patients and their families as our concerned stakeholders. Customized educational programs and telehealth services are influenced by patients’ need to manage their health conditions post-surgery, reduced readmission rates, and improved outcomes. The comprehensive discharge training and implementation are supported by the necessity of hospital management and healthcare providers to augment patients’ satisfaction levels, minimize costs associated with higher readmission rates, and improve healthcare quality. Since telehealth is included in our intervention plan, healthcare policies related to data protection and patient confidentiality are applicable. Health Insurance Portability and Accountability Act (HIPAA) is one of the crucial health policies that entails maintaining patient privacy, data security, and confidentiality when using telecommunication tools.

    Also, directing healthcare professionals to avoid unauthorized access (Kovac, 2021). Other than this, the regulations from governing bodies like the Centers for Medicare & Medicaid Services (CMS) define guidelines for telehealth reimbursement, and various state medical boards determine licensure and practice regulations, which assist providers in aligning their practices with standardized protocols. The underlying assumptions for this analysis are based on the factors that healthcare facilities should abide by national and state-level regulations to maintain care standards. Moreover, addressing the needs of the stakeholders will ensure their active involvement in the care process and adherence to the intervention plan. 

    Ethical and Legal Implications 

    The ethical implication in our intervention plan is autonomy vs. beneficence. While addressing patients’ right to receive care based on their preferences, it is essential to balance patients’ autonomy with the healthcare provider’s duty to act in the patient’s best interest. Customized educational plans can raise this ethical concern, where organizational changes should follow the moral principle of informed decision-making. This will allow providers to give detailed information on risks and benefits, respecting patients’ choices for their healthcare.

    On the other hand, organizations may face legal issues under the HIPAA act of maintaining patient privacy and data security while implementing telehealth services (Kovac, 2021). The use of healthcare technologies is governed by the legal duty of protecting patients’ health information. To fulfill legal standards, organizations must adhere to HIPAA policies, make stringent data protection security channels, inform patients about using their personal information, and safeguard the data using authorized access. Moreover, organizations must apply strict rules on healthcare providers to improve their compliance with HIPAA regulations. 


    In summary, our PICO(T) statement for Manatee Memorial Hospital suggesting comprehensive discharge education for post-cardiac catheterization patients is further designed into two interventional approaches – customized educational plans and telehealth services. Population and organizational cultural needs and characteristics impact our interventions. Moreover, Orem’s Self-Care Theory, Motivational Interviewing, and telecommunication tools, such as healthcare technology, influence the designing of these interventions as justified by credible resources. We have also included the aspects of stakeholders’ needs and healthcare policies that apply to our intervention plan and how ethical and legal implications can raise concerns. Addressing these concerns and abiding by the theoretical and regulatory framework is imperative to achieve improved patient outcomes and minimize the 30-day hospital readmission rate in discharged post-surgery cardiac patients.  


    Bischof, G., Bischof, A., & Rumpf, H.J. (2021). Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt International. 

    Chen, A., Ayub, M. H., Mishuris, R. G., Rodriguez, J. A., Gwynn, K., Lo, M. C., Noronha, C., Henry, T. L., Jones, D., Lee, W. W., Varma, M., Cuevas, E., Onumah, C., Gupta, R., Goodson, J., Lu, A. D., Syed, Q., Suen, L. W., Heiman, E., … Schmidt, S. (2023). Telehealth policy, practice, and education: A position statement of the society of general internal medicine. Journal of General Internal Medicine, 1–8. 

    Getha-Taylor, H., Holmes, M. H., & Moen, J. R. (2020). Evidence-based interventions for cultural competency development within public institutions. Administration & Society52(1), 57–80. 

    Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare – a scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLoS ONE14(7), e0219971. 

    Kaihlanen, A.-M., Hietapakka, L., & Heponiemi, T. (2019). Increasing cultural awareness: Qualitative study of nurses’ perceptions about cultural competence training. BMC Nursing18(1), 38. 

    Khademian, Z., Kazemi Ara, F., & Gholamzadeh, S. (2020). The effect of self-care education based on Orem’s nursing theory on quality of life and self-efficacy in patients with hypertension: A quasi-experimental study. International Journal of Community Based Nursing and Midwifery8(2), 140–149. 

    NURS FPX 6030 Assessment 3 Intervention Plan Design

    Kovac, M. (2021). HIPAA and telehealth: Protecting health information in a digital world. Journal of Intellectual Freedom & Privacy6(2), 6–9. 

    Krook, M., Iwarzon, M., & Siouta, E. (2020). The discharge process—from a patient’s perspective. SAGE Open Nursing6, 2377960819900707. 

    Santacroce, D. (2019). Culturally diverse discharge planning and education. Iris Journal of Nursing & Care1(2), 1–6. 

    U.S. Census Bureau. (n.d.). U. S. Census Bureau quickfacts: Bradenton City, Florida. 

    YU, H., ZHANG, P., WANG, X., WANG, Y., & ZHANG, B. (2019). Effect of health education based on behavioral change theories on self-efficacy and self-management behaviors in patients with chronic heart failure. Iranian Journal of Public Health48(3), 421–428. 

    NURS FPX 6030 Assessment 3 Intervention Plan Design