Project Committee Chairperson

Name:
__ ____________________________________________________

Signature: ___________________________________________________

Discipline:
___________________________________________________

Project Defended

On

[Month Day, Year]

Abstract

Acknowledgment

Table of Contents

Chapter

I. PROJECT INTRODUCTION …………………………………………………………… 8

Statement of Purpose ……………………………………………………………………….. 9

Theoretical Framework ……………………………………………………………………. 9

Initial Review of the Literature ………………………………………………………….13

Significance and Justification ……………………………………………………………19

Project Objectives ……………………………………………………………………………19

Definition of Terms ………………………………………………………………………..

Project Limitations …………………………………………………………………………

Project Development Plan ……………………………………………………………….

Plan for Protection of Human Subjects ……………………………………………..

Plan for Project Evaluation………………………………………………………………

Summary ………………………………………………………………………………………

II. REVIEW OF LITERATURE …………………………………………………………..

Summary ………………………………………………………………………………………

III. PROJECT DEVELOPMENT PLAN. ……………………………………………….

Project Setting and Population……………………………………………………..

Content Expert Participants …………………………………………………………….. Data Collection Methods …………………………………………………………………

Project Tools …………………………………………………………………………………

The Protection of Human Subjects ………………………………………………………

Summary ………………………………………………………………………………………

IV. PROJECT EVALUATION, IMPLICATIONS, AND FUTURE RECOMMENDATIONS

……………………………………………..

Project Evaluation ………………………………………………………………………….

Implications for Future Practice ……………………………………………………….

Future Recommendations ………………………………………………………………..

Summary ………………………………………………………………………………………

References ……………………………………………………………………………………. 21

Appendices ……………………………………………………………………………………

List of Appendices

Appendix

A D’Youville Patricia H. Garman School of Nursing Full Approval Letter

…………………….…. 60

B Letter of Intent ……………………………………………………………………………………. 62

C Evaluation Tool………………………………………………………………………………….. 64

D Educational training program……………………………………………………………………………………………… 66

E Survey tool results in graph……………………………………………….

The age of fast food and instant gratification brought about by the growth of technology has affected the general population in many ways. In America, obesity is becoming problematic, with a prevalence estimate of 41% leading to risk in the severity of diseases (Kalligeros
et al., 2020). As a result, there is a need for nursing practice to take accountability in developing a relationship with collaborative patient care. Obesity can be a lifestyle disease. Therefore, all stakeholder participation must be considered a need to look at the four-metaparadigm perspectives in caregiving using a foundational basis in a theoretical framework. First, a nurse needs expertise in addressing health issues, especially those reversible through natural means, for example, obesity. Obesity is reversible through natural means, including dietary modification and practicing fasting.

The factors that make a successful program include proper planning. Proper planning allows for allocating adequate time and resources toward the project, resulting in the successful implementation of the program (Shi, 2017). Another factor is incorporating experienced project managers with knowledge about the program. For example, specialists such as nutritionists and experts in physical activity and breastfeeding are essential when developing a program to improve nutrition in children and adults and minimize obesity. Finally, it is essential to practice monitoring and control for a program to succeed. Regular evaluation of the progress and the program results allows for modification and alignment in case of an error or a potential error—effective communication results in a program’s success.

Hildegard Peplau’s (2004)
Interpersonal Relations in Nursing Theory is the theoretical framework for developing this project. A brief overview of the theory is presented, and a discussion regarding how the theory was utilized to guide the project’s development. In addition, Peplau’s (2004) theoretical definitions for nursing’s four metaparadigm concepts and the Project Author’s operational definitions will be presented. These metaparadigm concepts include orientation, identification, exploitation, and resolution defined within nurse, health, patient, and environments aspects of nursing healthcare provision. As such, the theory emphasizes the importance of crosscutting issues and their effect on nursing care and patient wellness, such as nursing education on dietary interventions for patients with obesity, as in this study.

It thus facilitates better planning to understand the complexities of issues underlying the patient’s conditions, which would hinder getting well. Therefore, this project aims to bring to attention the definition of the metaparadigm concept of patient care within this theory by looking at its significance and interpersonal relationship as contextualization in patient care as a tool for promoting patient education on a healthy diet. In this essence, the project will look at its application as employed in modern nursing care—concerning how the patient-nurse relationship influences the efficiency of healthcare delivery through patient education and implementation of the interventions, i.e., education on a healthy diet for patients with obesity. Finally, the deliberate look of this theory within this aspect will facilitate a conclusion on the modern-day emphasis and necessitated patient-centered model of care.

As a mother of nursing psychiatry, Peplau (2004) describes interpersonal relations as a conditional aspect that includes first the interaction of the nurse and patient. She points out that this is attained when understanding each patient’s condition is an experience that allows for improving nursing care (Peplau, 2004). Therefore, the focus in the definition of the theory begins with grasping the nurse and patient metaparadigm concepts as the interaction between patient and nurse makes the relationship personal. Similarly, considerable insights thus point out that the patient care process is personalized in a way that responsibility is both technical and emotional. Peplau (2004) explains that effective patient outcome delivery comes from trust in diagnostics and, thus, acceptance of health as an essential metaparadigm aspect.

The nurse-patient interaction and the collaboration mechanisms between them to attain health are the main topics of Hildegard Peplau’s middle-range theory of interpersonal relations. The nurse and patient can achieve the healthcare objective together by completing a series of distinct stages in a precise sequence. The patient can continue with that path even after the partnership ends. This hypothesis is crucial since it explains how the nurse-patient interaction might improve the patient’s comprehension of the value of the treatment they are receiving. Once the patient is well-informed about their treatment, they can carry on implementing the interventions to attain wellness without the nurse’s ongoing assistance (Peplau, 2004). This theory is a perfect fit for the proposed educational training program for nurses in an outpatient setting to provide education regarding the importance of a healthy diet for patients with obesity. The relationship between the outpatient and the nurse must be founded on trust so that information can be shared comfortably and with trusted support from nurses (Peplau, 2004). A support system must be developed because obesity and the issues surrounding obesity can often bleed into self-esteem and mental health. This theorist ideology will assist in identifying and orienting nurses to the causes of obesity, introducing a perfectly balanced diet with regular exercise, and finally producing solutions for diabetic prevention, a foundation that this theoretical framework supports.

Hildegard Peplau’s theory is significant and relevant to this project because it supports the notion that nursing encompasses beyond simply administering medications and tending to wounds. Patients can preserve their health to the highest possible standard by being informed about their therapy’s reasons and composition. In addition, Peplau’s theory provides information on how the nurse can relate to the patient in a way that promotes comfort and the sense of patient control of their treatment. Also, it makes the patient feel like the treatment can be carried out independently after being discharged from the nurse’s care (Peplau, 2004).

Thus, nursing can be defined based on culture and concrete work (Peplau, 2004). Thus, it promotes health through appropriate methods and illness prevention by recognizing triggers for all patients. Therefore, the nurse can only facilitate treatment and not make a diagnosis; hence, the critical aspect is ensuring that the environment is conducive and that communication in the relationship with patients is constant. This means the nurse favors patients’ understanding of their issues by explaining the problem and the treatment plan. This includes a preventive measure to ensure informed decision-making is enhanced and, thus, a partnership that, in essence, is therapeutic.

Communicative action in the digital age between nurse and patient is bold navigation of interpersonal relationships. On the other hand, the increase in maintenance tendency takes a newer approach, as information overload can be present due to media. This could be advantageous for outpatient care, but the opposite is true. As such, following Peplau’s underpinning of patient care, nursing is the implementation of need-based healthcare delivery through the respectable promotion of perception and prevention of escalation of illness (Peplau, 2004). Therefore, it can be said that the operational definition of nursing is ensuring that patient needs are met adequately and suitably hence unique to the patient. With that, a different relationship develops between nurse and patient.

In recognition, a person is operationally defined as an entity with individual preconceptions and a mutual understanding of the nature of a medical issue and collaborates towards a productive solution. Therefore, this contextualizes the environment as conditions that allow for human processes that facilitate tendencies supportive of positive development to attain health (Peplau, 2004, p. 12). By this definition, health can operationally be defined as a symbolic future positive goal that is attained after effective healthcare hence instrumental for the person moving in the forward direction of well-being (Peplau, 2004, p. 13).

Operations Definition of Nursing Metaparadigm under Interpersonal Relations Nursing Theory

For this project, the operational definition of the nurse is a supporter who ensures that patient needs are unique and met adequately and suitably to their circumstance. This recognizes that a different relationship develops between nurse and patient from one. In the same stance, a person is operationally defined as an entity with individual preconceptions and a mutual understanding of the nature of a medical issue. Within this understanding, they can collaborate with informed decision-making toward a productive solution. It thus supports the operational definition of the environment as contextualized conditions that allow for human processes that facilitate tendencies supportive of positive development to attain health (Peplau, 2004, p. 12). By this definition, there is support for operationally defined health as a symbolic future positive goal attained after effective healthcare, which is instrumental for the person moving in the forward direction of well-being (Peplau, 2004, p. 13).

According to Balani
et al. (2019), the epidemic of obesity is a significant health crisis that continues to increase globally. It is reported that in the United States, more than two-thirds of adults are considered either overweight or obese. Therefore, a lifestyle disease is critical to the discussion on nursing care for outpatient obesity. As such, care focuses on management and fostering better and healthy weight maintenance (Kalligeros
et al., 2020). Thus, it does not necessarily focus on age but understands that eagerness is also a risk factor for comorbidities associated with being overweight.

Furthermore, Kalligeros
et al. (2020) study point out that the exploration of the association between obesity and chronic diseases is something that should be understood. This is because there is a direct relation between the severity of the outcomes seen in intensive care units and admission rates. For example, research that analyzes a retrospective cohort with 103 patients found that of the patients admitted to the hospital history of heart disease is a direct result of obesity. Therefore, a recommendation is that vigilance should be given to treating patients with obesity starting from the outpatient setting, alluding to necessitated prevention of escalation when faced with other conditions (Kalligeros
et al., 2020).

The role of nursing is to provide integrated care and enhance patient comfort by providing interventions to alleviate symptoms of obesity. Findings from Rezaei
et al. (2022) study point out that high morbidity rates are caused by poor health maintenance, which aligns with the results in Smith
et al.’s (2020) and Sutaria
et al. (2020) studies. Furthermore, Gadde
et al. (2018) study findings indicate a significant reduction in morbidity and mortality rates among patients in weight maintenance trials. The high number of obesity cases creates a risk factor in the population; this points to the need to emphasize training for this. Recognizing physician efforts in collaboration with outpatients by sensitization on environmental awareness is essential (Walia
et al., 2022). This includes considering that proper evaluation starts by recognizing the appropriateness of the environment for supporting weight management. Achieving and maintaining weight loss or gain requires physician-patient collaboration in a way that can be facilitated by nurses providing pertinent information. Again, support and motivation are also determined by letting a carefully defined plan be identified with the patient to understand the expected health outcomes. This is the nurse’s work as it allows for the recognition of a strategy of control for each patient (Stonerock & Blumenthal, 2017:p.1457).

According to Rezaei
et al. (2022), the combination of aspects such as the cost of health, care expenditures, and hospitalization risks are some of the reasons that can be used in motivating outpatients to adhere to their plan of losing weight. This study aligns with the findings of Piché
et al. (2020) study findings. The findings indicate that advanced heart diseases are often caused by obesity and lack of maintenance, and the determinant of failure lies in the early handling of the issue. Therefore, health literacy is an integral part of the nursing fraternity to impart to the patients as it allows for the opportunity to understand the implication of obesity in the long run. Consequently, the narrative is applicable because by the time medication is involved. The progression will be higher risk associated and thus significant mortality risk. However, creating a provider-patient relationship with a healthy diet, diabetes, and obesity teaching without having a judgmental response, whereby both parties agree on goals and share a vision of improvement in general metabolic health status, is beneficial. The patient and provider can create a personalized and participatory lifestyle change plan as described by Foley
et al. (2019) study. Furthermore, Alexander
et al. (2021) study findings indicate that health literacy as part of outpatient training will provide the necessary support for proper weight loss and maintain it while allowing room for recognition of mental health too. This caters to the grasping of the incorporation of strategies that align outcomes centered on the totality of patient care within the six sigma of quality improvement in healthcare delivery.

Alexander
et al. (2021) research focuses on promoting healthcare delivery as a focal point in preventive care and is supported by Levine
et al. (2019), which look at a similar issue but with a different approach. Levine
et al. (2019) surveyed to find out why the use of preventive healthcare is still low in the modern healthcare system. The findings from the survey linked modernization and the advancement in technology as one the contributors to the limited use of preventive medicine. Nevertheless, Harris
et al. (2017) point out how using preventive healthcare would enhance the efficiency of care and result in better outcomes. Therefore, Alexander
et al. (2021), Levine
et al. (2019), and Harris
et al. (2017) studies collectively look at transitioning patients from outpatient to inpatient and provide insight into what to avoid and what is necessary to promote better care. From the start, the studies allow room for relativity in practices that promote and optimize safety, and within those points to the relevance of individual patient circumstances. While the paper gives valuable information on the standard procedure, it contributes to the general discussion on the improvement of health by nurses. It thus applies that, for all patients, recognition of the value in situation background assessment facilitates the improvement of health outcomes. The improvement starts with a reduction in risks hence understanding beneficial outcomes accurately first (Alexander
et al., 2021).

There is also a need to recognize the impact of cultural competency in nursing care (Chae & Park, 2019). With outpatients, there is a risk of exposure to external biases and pressure that may result in declining health whenever they leave a session. Therefore, value must be provided in educating patients on the potential risks they face in their environment. This can only be achieved through collaboration which aligns with the results of Seger’s (2019) and Ogbolu
et al. (2018) studies. Furthermore, it is essential for the patient’s perspective of the community and support system to be observed by the patient (Bloor & McIntosh, 2019). Therefore, sharing with the nurse is a natural step of goal setting that allows an informed understanding of the underlying implication of the stereotypes and norms of expectation (Halvorson
et al., 2019). This will help focus on reducing the risk of “temptation” of hindrances to improving patient health in a way that respects them and their communities.

Similarly, (Balani
et al., 2019) study examined factors affecting healthy weight in the community. The study explained that obesity is not a lifestyle crisis but rather a complicated, chronic disease affecting areas of behavioral, psychosocial, biological, and environmental factors. For this reason, there is a need for a collaborative and comprehensive approach to obesity management. Therefore, foundational planning is essential for the nurse and the patient to recognize early on.

Hee Soon
et al. (2019) opted to conduct a study on this subject .focusing on the younger populations; one thing that tends to be overlooked is that children learn from what they see happening in their surroundings. Thus, even if a child is prone to eating healthy in their respective homes, they are also prone to be influenced by what they see in schools or other surroundings. Therefore, this research study aimed to answer the question, “What are the barriers at home and school to healthy eating?” Furthermore, it also aimed at answering this through the perspectives of parents and children who had or were suffering from obesity; therefore, parents, teachers, and community healthcare providers should alleviate the issues of obesity through adequate healthy diet teaching and implementation.

It is imperative when it comes to the management of unvoiced expectations of a patient in a way that recognizes their efforts and input toward change. According to Ma
et al. (2019) study findings, obesity management requires self-discipline at a higher level than average and recognizing a gradual result, supported by Reas’s (2017) study. These studies describe how lack of self-discipline results in binge eating disorder; at the same time, public and healthcare professionals’ knowledge and attitudes toward the relationship between self-awareness results in binge eating disorder and, consequently, weight gain (obesity). The fact that it cannot be cured by medication and results are not immediate is a cause of concern that both nurse and patient should understand (Boersema
et al., 2021:p.11). It requires patience and a lens where small milestones can only weigh competent management. Furthermore, obesity practitioners must have complete comprehension and apply evidence-based knowledge while administering care to patients with obesity (Srivastava
et al., 2019:p.196).

When management optimization is needed in the treatment strategy for a patient with obesity, especially outpatients, there is a need for longitudinal consideration of the comprehensiveness of management aspects. According to Seger (2019), a complication of obesity as a chronic illness is as sophisticated as any other issue, which aligns with Godfrey
et al. (2017) study. Godfrey
et al. (2017) describe the complications primarily associated with maternal obesity, including coronary artery disease, obesity in the offspring, asthma, and allergies. In addition, Schetz
et al. (2019) describe obesity as one of the current health concerns affecting a large proportion of the world’s population. As such, an intensity level should be employed with preventive controls in line with the responsibility set. This allows for desired treatment to be the main goal rather than the desired end product, such as specific weight. It removes the tension without negating the implication of the process and thus optimizes input by the small measures that can be seen regularly. Therefore, a pathophysiological approach is necessary for an all-hands-on methodology hence simplicity that is specific to the patient in question rather than a generalization as in Block
et al. (2020) study findings.

Inadequacy of skills and knowledge among healthcare professionals is one of the significant challenges facing the fight against metabolic conditions such as obesity. Bucher Della Torre
et al. (2018) describe one of the challenges in one of the university hospitals as the presentation of poor knowledge, skills, and attitude about obesity among nurses and physicians, which aligns with the findings of Turner
et al.’s (2018) study. Turner
et al.’s study revealed inadequate knowledge concerning managing obesity effectively. The results imply that provider perception of optimal healthcare services for obesity is at odds with research-based guidelines. Healthcare practitioners must be aware of the best ways to use pharmacotherapy and behavioral counseling, such as adopting a healthy diet; these interventions are widely applied in improving the health of obese patients (Turner
et al., 2018:p.667).

Reinforcing Positive environment in Nurse-Patient Relationship

Project Objectives

The objectives of this project are to:

1. Conduct an extensive review of the literature exploring healthy diets for patients with obesity using the following keywords, both singularly and in multiple combinations: nursing training, obesity, obesity prevention, outpatient care, overweight, diet, and healthy diet. Databases searched, limited to the years 2017 to 2022, will include AMED, Alt Health Watch, CINAHL Plus with Full Text, EBSCO, Medical Journal sites for nursing care, nursing training, PubMed, Scopus, Science Direct, Directory of Open Access Journals, Google Scholar, JSTOR and the D’Youville library to loan articles through interlibrary loan;

2. Develop a (resource guide; brochure, PowerPoint, Video); and

3. Have a panel of five content experts with extensive knowledge and expertise in a healthy diet for patients with obesity evaluate and critique the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.

Definition of Terms

The following concepts are defined both theoretically and operationally for the purpose of this project:

Health Promotion

Theoretical Definition: Behavior motivated by the desire to increase well-being and actualize human health potential. It is an approach to wellness (Pender
et al., 2011, p. 45).

Operational Definition: Behaviors that promote HGH treatment delivery and adherence resulting in improved health, treatment outcomes, and better quality of life for adolescents diagnosed with HGH deficiency.

Body mass index (BMI)

Theoretical Definition: BMI refers to a person’s weight in kilograms divided by the square of height in meters.

· Normal (BMI reading: 18.5 kg/m2≤ BMI 25 kg/m2

· Overweight BMI measure: 25 kg/m2≤ BMI 30 kg/m2

· Obese BMI: ≥ 30 kg/m2 (Xiang & An, 2015)

Operational Definition: BMI is a clinical measurement tool to determine if a person may have elevated body mass obtained by dividing a person’s weight in kilograms by the square of their height in meters.

Theoretical definition: Refers to both a health-promoting and disease-preventing diet. It delivers adequate nutrients and other health-promoting ingredients from wholesome foods while avoiding ingesting harmful substances (Chaudhary
et al., 2018, p.3).

Operational Definition: A diet composed of macronutrients, micronutrients, and vitamins necessary for maintaining the body’s normal functioning and promoting health through enhancing healthy weight loss in obese patients.

Limitations

The Project Author recognizes the following project limitations:

1. The implementation of the (PowerPoint); is not within the context of this project;

2. The (product) is developed in the English language only and may benefit a more culturally diverse population if written in additional languages.

Project Development Plan

Start here

Instructions for the Plan for the Protection of Human Subjects section

This section follows the Project Development Plan section and discusses each of the required components noted in the D’Youville IRB Manual regarding how the safety, privacy, and rights of the human subjects (the content experts) will be protected. This section should be presented as follows:

Plan for the Protection of Human Subjects

Following approval from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), (5) professionals with knowledge and expertise in the area/field of
will be personally approached and asked to voluntarily participate as a content expert in the review and evaluation of the (product) (Appendix D). Content experts will be advised that participation or non-participation as an expert reviewer will have no effect on their employment status. The Project Author has a collegial, professional, and non-supervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. Content experts will be guaranteed confidentiality because identifying characteristics will not be collected on the Content Expert Project Evaluation Tool and because their names will not be revealed anywhere in the project manuscript or in required project presentations. Only the Project Author will know the names of the content expert reviewers. Return of the completed content expert Project Evaluation Tool (Appendix C) will indicate implied voluntary consent to participate as a content expert reviewer. Content experts will be advised that they will not be able to withdraw from project participation once the project evaluation tool is returned to the Project Author because the evaluation tool will be returned without identifying information. Returned Content Expert Project Evaluation Tools will be stored according to the D’Youville Patricia H. Garman School of Nursing protocol in a locked drawer located in the Project Author’s (home/office) for a period of (three years (US)/six years (Canada)) and then destroyed.

11. Instructions for the Plan for Project Evaluation section

The Plan for Project Evaluation section follows the Plan for the Protection of Human Subjects section and discusses plans regarding how the project will be evaluated and how data resulting from the project evaluation will be analyzed. Tools developed to evaluate the project need to be included in the Appendices. When discussing the evaluation tool in the body of the project manuscript, the student needs to make sure that the order of items is presented as they appear on the evaluation tool. The Plan for Project Evaluation section should be presented as follows:

Plan for Project Evaluation

After obtaining full approval from the D’Youville Patricia H. Garman School of Nursing (Appendix A), the Project Author will mail a packet to each content expert reviewer containing one Letter of Intent (Appendix B), one copy of the Content Expert Project Evaluation Tool (Appendix C), one copy of the (product) (Appendix D), and one self-addressed stamped envelope. The Letter of Intent will explain the project purpose and instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author.

The Content Expert Project Evaluation Tool will consist of (6) evaluative items scored on a four- point Likert Scale that ranges from (1) Strongly Disagree. (2) Disagree, (3) Agree, and (4) Strongly Agree. Space will be provided for narrative comments and suggestions following each evaluative item. Evaluative items will ask reviewers to rate the (product) on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. Approximately 20 minutes will be required to review the (product) and to complete the Content Expert Project Evaluation Tool. Content experts will be given (7) days to complete and return the Content Expert Project Evaluation Tool to the Project Author via postal mail using the self-addressed stamped envelope included in the original packet. Likert scale responses will be presented narratively and displayed in (tabular/bar graph) format. Content expert suggestions and comments will be analyzed for common themes and presented narratively. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tool will be provided to the content expert reviewers by postal mail.

*

Make sure the order of evaluative items in your content expert evaluation tool is stated in the same order in the body of your proposal.

12. Instructions for the Summary section

The Summary section follows the Plan for Project Evaluation section. The Summary section consists of one paragraph that briefly summarizes what was completed in Chapter I of the project proposal. The summary is written in past tense and should be presented as follows:

Summary

Summary

REDO THE SUMMARY–You should start like
this –>Chapter I presented the project introduction, statement of purpose, an overview of the theoretical framework guiding project development, an initial review of the literature focusing on

There are several reasons why people seek medical attention. The project improved the APRNs’ understanding of obesity among those who work in an outpatient setting. The practitioner can better comprehend the need to interact with an obese patient by applying interpersonal relations nursing theory concepts. This gives practitioners a structure when guiding a discussion with patients about their weight control. To achieve healthy body weights and lead healthy lifestyles, one must consume adequate nourishment and follow a healthy diet (Healthy People 2020, 2011). Improving health and well-being will result from eliminating obesity in the long run.

The first chapter of this project introduced the topic and stated the purpose. Then, the chapter elaborated on the theoretical framework, discussing the nursing theory on which the project will be based, its significance, and the concepts concerning the project’s aim. Other topics discussed in the initial chapter are the project significance and justification, objectives, the definition of terms, project limitations, and the project development plan. A detailed examination of the literature on establishing an educational plan for nurses working in an outpatient setting to equip them with knowledge on healthy diets for patients with obesity will be provided in Chapter II, along with a chapter summary. The third chapter of the project will entail the planned project setting and population, the participating topic experts, data collection techniques, project instruments, and a chapter summary. Finally, chapter IV will cover the project’s evaluation, implications for future advanced nursing practice, suggestions for further projects and research, and a chapter summary.

References

Alexander, C. C., Tschannen, D., Hays, D., Clouse, M., Zellefrow, C., Amer, K. S., & Milner, K. A. (2022). An integrative review of the barriers and facilitators to nursing engagement in quality improvement in the clinical practice setting.
Journal of Nursing Care Quality, 
37(1), 94-100.

Alexander, C., Rovinski-Wagner, C., Wagner, S., & Oliver, B. J. (2021). Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff. 
Journal of Nursing Care Quality, 
36(3), 195-201.

Allan, J. (2020). Theorizing new developments in critical social work. In
Critical social work (pp. 30–44). Routledge.

Block, B. L., Smith, A. K., & Sudore, R. L. (2020). During COVID‐19, outpatient advance care planning is imperative: We need all hands on deck. 
Journal of the American Geriatrics Society.

Healthy People 2020. (2011). Topics & objectives index. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/default.aspx

Xiang, X., & An, R. (2015). Obesity and onset of depression among US middle-aged and older adults. 
Journal of Psychosomatic Research, 
78(3), 242–248.