M.

KELLY DNP PROJECT PROPOSAL 1

PROJECT DESCRIPTION

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

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

• Increase the ability of practicing nurses to include patients and families in management of chronic
disease outside of the hospital setting.

PROJECT OUTCOME
Sixty nurses in California will complete the Care Transitions knowledge-attitude & practice (KAP)
survey. Results will be analyzed for major themes, which will guide the design and implementation of
future activities that build on care transition competencies in nursing practice in California.
 M. KELLY DNP PROJECT PROPOSAL 2

PROJECT TIMELINE ACTIVITIES & APPROACHES

MILESTONE 09-15-09 to 12-01-
09

1. Develop survey October 2009 Develop survey questionnaire.

October 2009 Pilot survey questionnaire on ten nurses, analyze quality of

2. Pilot survey
results. Redesign and pilot again as needed.
November 2-3 Attend California Institute of Nursing and Health Care
2. Conduct KAP
(CINHC) conference. Have booth set up to invite nurses to
survey
participate in survey. Have incentives available.
November 4-7 Analyze survey results of Care Transitions. Use coding to
4. Analyze/evaluate
identify predominate themes in responses.
5. Summarize November 8-16 Evaluate themes for clarification of barriers and opportunities
findings to the implementation of care transitions learning activities.
November 19th Design plan for implementation and dissemination of Care
Transitions learning tools, which include components for
7. Finalize report
sustainability.
*Comprehensive Report of Project to Committee
December 8th am *Present DNP Project
6. Present/defend
2009

Note * items are final DNP degree requirements.

INIATIVE OUTCOME
To positively influence the direction of nursing practice by providing opportunities for nurses to
integrate the Care Transitions Intervention into the professional nursing roles and practice. As nurses
become competent in safely transitioning clients with chronic disease between care settings, it may be
possible to increase quality of life, reduce health care costs and support clients’ capacity for autonomy
through self-care.

SURVEY EVALUATION
Categorical and open-ended questions will be employed in the survey design; responses will be
reviewed and evaluated using thematic analysis.

REFERENCES
Parry, C., Coleman, E., Smith, J., Frank J., & Kramer, A. (2004). Preparing Patients and Caregivers to

Participate in Care Delivered Across setting: The Care Transitions Intervention. Journal of the

American Geriatrics Society, 52(11), 1817-1125.