Assignment Prompt & Instructions
Quin cap Edit this document
– ## Capstone_Assessment4.docx
– ## capstoneassignment4.docx
**## Capstone_Assessment4.docx**
Diabetes Management: A Nurse-Led Family-Centered Intervention
Quincy Kimani
Capella University
Capstone Project
Amanda De La Serna
9/18/2025
## Introduction
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder that presents significant challenges to patients, families, and healthcare systems. In families where multiple members are diagnosed with T2DM, management becomes complex due to the cumulative burden of medication adherence, lifestyle modification, and psychosocial stressors. This project focuses on diabetes management within a family system, recognizing that family engagement and education are central to effective disease control. The problem is highly relevant to nursing practice because nurses play pivotal roles as educators, coordinators, and advocates for holistic, evidence-based care.
## Proposed Intervention
The proposed intervention is a nurse-led, family-centered diabetes self-management education and support (DSMES) program. The intervention integrates telehealth technology, continuous glucose monitoring (CGM), and community-based resources to strengthen adherence and improve outcomes. A teaching plan will be used as the professional product, focusing on family education about diet, medication adherence, lifestyle change, and use of digital tools for monitoring. Nurse facilitators will conduct structured telehealth sessions to guide the family, provide culturally tailored education, and foster collaborative goal-setting.
## Role of Leadership and Change Management
Nurse leadership is essential in mobilizing families and care teams toward improved diabetes outcomes. By applying Lewin’s Change Theory, the intervention emphasizes unfreezing current behaviors, moving toward new lifestyle patterns, and refreezing sustainable self-management practices. Nursing ethics also inform this intervention by ensuring respect for autonomy, justice in equitable access to resources, and beneficence through promotion of well-being. Leaders will encourage shared decision-making, while motivational interviewing techniques will be used to overcome resistance to change within families.
## Communication and Collaboration Strategies
The intervention identifies the family unit as the primary patient group. Effective communication and collaboration are necessary to ensure consistent adherence to care plans. Gathering input from each family member fosters ownership and strengthens natural support systems. Best practices supported by literature include the use of motivational interviewing, culturally sensitive education, and structured family meetings to establish shared goals. Collaboration among nurses, dietitians, primary care providers, and community health workers will enhance continuity of care and prevent fragmentation.
## Policy and Nursing Standards
The intervention is guided by the 2022 National Standards for DSMES and the American Diabetes Association (ADA) 2025 Standards of Care. These emphasize patient-centered, team-based approaches and the integration of social determinants of health in diabetes care. Scope-of-practice policies that empower advanced practice nurses to lead educational and coordination efforts further support this model. Research demonstrates that DSMES and nurse-led models significantly improve glycemic outcomes, reduce complications, and increase patient satisfaction.
## Impact on Quality, Safety, and Costs
The proposed intervention will enhance quality of care by empowering families with the knowledge and skills to self-manage diabetes. Patient safety is prioritized through the use of CGM and telehealth monitoring, which help prevent episodes of hypo- and hyperglycemia. By reducing hospital readmissions and emergency visits, the program is expected to lower costs for both families and the healthcare system. Benchmark data from ADA and CDC reports support that DSMES reduces complications and improves long-term cost-effectiveness.
## Technology, Care Coordination, and Community Resources
Technology plays a central role in this intervention. Telehealth platforms will provide remote education and follow-up, while mobile health applications and CGMs will allow real-time monitoring of glucose levels. Care coordination will involve linking patients to dietitians, primary care providers, and community health workers to promote continuity. Community resources, including diabetes support groups and nutrition classes, will supplement clinical care and address psychosocial needs. Evidence shows that integration of technology, coordinated care, and community-based supports improves self-management, satisfaction, and clinical outcomes.
## Conclusion
Diabetes management in families affected by T2DM requires holistic, evidence-based strategies that incorporate technology, policy, and community resources. The nurse-led, family-centered DSMES program described here addresses these needs by empowering patients and families, improving safety, and reducing costs. By leveraging leadership, collaboration, and change management strategies, this intervention is poised to improve both short-term and long-term outcomes, and is submitted for faculty review and approval as part of the capstone project.
## References
American Diabetes Association. (2025). Improving care and promoting health in populations: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S14–S26. https://doi.org/10.2337/dc25-S001
Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., … & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. Diabetes Care, 45(2), 484–494. https://doi.org/10.2337/dc21-2396
Dailah, H. G. (2024). The influence of nurse-led interventions on diseases management in patients with diabetes mellitus: A narrative review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352
Johnson, C., Ingraham, M. K., Stafford, S. R., & Guilamo-Ramos, V. (2024). Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nursing Outlook, 72(4), 102191. https://doi.org/10.1016/j.outlook.2024.102191
Macedo, V. L. M. D., Sousa, N. P. D., Santos, A. C. D., Santos, W., Stival, M. M., & Rehem, T. C. M. S. B. (2025). Coordination of care in health systems for users with diabetes and hypertension: A scoping review. Revista Latino-Americana de Enfermagem, 33, e4428. https://doi.org/10.1590/1518-8345.7198.4428
Busebaia, T. J. A., Thompson, J., Fairbrother, H., & Ali, P. (2023). The role of family in supporting adherence to diabetes self-care management practices: An umbrella review. Journal of Advanced Nursing, 79(10), 3652–3677. https://doi.org/10.1111/jan.15689
**## capstoneassignment4.docx**
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.
Expand All
**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**: As you revise your writing, check out the resources listed on the Writing Center's
[Writing Support](https://campustools.capella.edu/redirect.aspx?linkid=4646) page.
**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.
**Additional Requirements**
·
**Format**: Format the written analysis of your intervention using APA style.
[APA Style Paper Tutorial [DOCX]](https://campustools.capella.edu/redirect.aspx?linkid=4243) is provided to help you in writing and formatting your paper. Be sure to include:
· A title page and reference page. An abstract is not required.
· Appropriate section headings.
·
**Length**: Your paper should be approximately 5–7 pages in length, not including the reference page.
·
**Supporting evidence**: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.
·
**Proofreading**: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance.
**Portfolio Prompt**: Save your intervention to your
[ePortfolio](https://campustools.capella.edu/redirect.aspx?linkid=1688). After you complete your program, you may want to consider leveraging your portfolio as part of a job search or other demonstration of your academic and professional competencies.
**Competencies Measured**
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
· Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.
· Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care.
· Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
· Competency 4: Apply health information and patient care technology to improve patient and systems outcomes.
· Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
· Competency 5: Analyze the impact of health policy on quality and cost of care.
· Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
· Competency 6: Collaborate interprofessionally to improve patient and population outcomes.
· Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
· Competency 8: Integrate professional standards and values into practice.
· Write concisely and directly, using active voice.
· Apply APA formatting to in-text citations and references.
Please submit both your solution/intervention and the 5–7 page analysis to complete Assessment 4.
**Scoring Guide**
Use the scoring guide to understand how your assessment will be evaluated.
Expand All
**Criterion 1**
**Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.**
**Distinguished**
Defines the role of leadership and change management in addressing a patient, family, or population health problem. Provides an articulate, cogent explanation of the influence that leadership strategies, change management strategies, and nursing ethics had on the development of an intervention and includes a copy of the intervention/solution/professional product.
**Proficient**
Defines the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of the intervention/solution/professional product.
**Basic**
Attempts to describe leadership and change management strategies, and/or does not include a copy of the intervention/solution/professional product.
**Non Performance**
Does not describe leadership and change management strategies, and does not include a copy of the intervention/solution/professional product.
**Criterion 2**
**Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.**
**Distinguished**
Proposes clear, best-practice strategies, well-supported in the literature, for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem. Presents a strong case for the benefits of obtaining input from a patient, family, or group.
**Proficient**
Proposes strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
**Basic**
Attempts to describe communication and collaboration strategies.
**Non Performance**
Does not describe communication and collaboration strategies.
**Criterion 3**
**Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.**
**Distinguished**
Provides an articulate, cogent explanation of how specific state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention. Describes credible research on the effectiveness of these standards and/or policies in improving outcomes.
**Proficient**
Explains how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Basic**
Attempts to explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Non Performance**
Does not describe state board nursing practice standards and/or organizational or governmental policies applicable to the development of a proposed intervention.
**Criterion 4**
**Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.**
**Distinguished**
Provides an articulate, cogent explanation of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Conclusions are well-supported by credible evidence. Cites specific, relevant, and available sources of benchmark data.
**Proficient**
Explains how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Basic**
Provides an explanation, dependent upon unsubstantiated assumptions, of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Non Performance**
Does not explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Criterion 5**
**Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.**
**Distinguished**
Provides an articulate, cogent explanation of how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem. Conclusions are well-supported by specific, credible evidence.
**Proficient**
Explains how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
**Basic**
Attempts to explain how technology, care coordination, and community resources can be applied in addressing a patient, family, or population health problem.
**Non Performance**
Does not describe technology, care coordination, and community resources that can be applied in addressing a patient, family, or population health problem.
**Criterion 6**
**Write concisely and directly, using active voice.**
**Distinguished**
Writes concisely and directly. Conveys precise and unequivocal meaning through clear and consistent use of active voice.
**Proficient**
Writes concisely and directly, using active voice.
**Basic**
Writes passively, with a tendency toward wordiness.
**Non Performance**
Does not write concisely and directly, using active voice.
**Criterion 7**
**Apply APA formatting to in-text citations and references.**
**Distinguished**
Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
**Proficient**
Applies APA formatting to in-text citations and references.
**Basic**
Applies APA formatting to in-text citations and references incorrectly and/or inconsistently, detracting noticeably from good scholarship.
**Non Performance**
Does not apply APA formatting to in-text citations and references.
**## capstoneassignment4.docx**
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.
Expand All
**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**: As you revise your writing, check out the resources listed on the Writing Center's
[Writing Support](https://campustools.capella.edu/redirect.aspx?linkid=4646) page.
**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.
**Additional Requirements**
·
**Format**: Format the written analysis of your intervention using APA style.
[APA Style Paper Tutorial [DOCX]](https://campustools.capella.edu/redirect.aspx?linkid=4243) is provided to help you in writing and formatting your paper. Be sure to include:
· A title page and reference page. An abstract is not required.
· Appropriate section headings.
·
**Length**: Your paper should be approximately 5–7 pages in length, not including the reference page.
·
**Supporting evidence**: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.
·
**Proofreading**: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance.
**Portfolio Prompt**: Save your intervention to your
[ePortfolio](https://campustools.capella.edu/redirect.aspx?linkid=1688). After you complete your program, you may want to consider leveraging your portfolio as part of a job search or other demonstration of your academic and professional competencies.
**Competencies Measured**
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
· Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.
· Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care.
· Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
· Competency 4: Apply health information and patient care technology to improve patient and systems outcomes.
· Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
· Competency 5: Analyze the impact of health policy on quality and cost of care.
· Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
· Competency 6: Collaborate interprofessionally to improve patient and population outcomes.
· Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
· Competency 8: Integrate professional standards and values into practice.
· Write concisely and directly, using active voice.
· Apply APA formatting to in-text citations and references.
Please submit both your solution/intervention and the 5–7 page analysis to complete Assessment 4.
**Scoring Guide**
Use the scoring guide to understand how your assessment will be evaluated.
Expand All
**Criterion 1**
**Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.**
**Distinguished**
Defines the role of leadership and change management in addressing a patient, family, or population health problem. Provides an articulate, cogent explanation of the influence that leadership strategies, change management strategies, and nursing ethics had on the development of an intervention and includes a copy of the intervention/solution/professional product.
**Proficient**
Defines the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of the intervention/solution/professional product.
**Basic**
Attempts to describe leadership and change management strategies, and/or does not include a copy of the intervention/solution/professional product.
**Non Performance**
Does not describe leadership and change management strategies, and does not include a copy of the intervention/solution/professional product.
**Criterion 2**
**Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.**
**Distinguished**
Proposes clear, best-practice strategies, well-supported in the literature, for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem. Presents a strong case for the benefits of obtaining input from a patient, family, or group.
**Proficient**
Proposes strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
**Basic**
Attempts to describe communication and collaboration strategies.
**Non Performance**
Does not describe communication and collaboration strategies.
**Criterion 3**
**Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.**
**Distinguished**
Provides an articulate, cogent explanation of how specific state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention. Describes credible research on the effectiveness of these standards and/or policies in improving outcomes.
**Proficient**
Explains how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Basic**
Attempts to explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Non Performance**
Does not describe state board nursing practice standards and/or organizational or governmental policies applicable to the development of a proposed intervention.
**Criterion 4**
**Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.**
**Distinguished**
Provides an articulate, cogent explanation of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Conclusions are well-supported by credible evidence. Cites specific, relevant, and available sources of benchmark data.
**Proficient**
Explains how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Basic**
Provides an explanation, dependent upon unsubstantiated assumptions, of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Non Performance**
Does not explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Criterion 5**
**Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.**
**Distinguished**
Provides an articulate, cogent explanation of how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem. Conclusions are well-supported by specific, credible evidence.
**Proficient**
Explains how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
**Basic**
Attempts to explain how technology, care coordination, and community resources can be applied in addressing a patient, family, or population health problem.
**Non Performance**
Does not describe technology, care coordination, and community resources that can be applied in addressing a patient, family, or population health problem.
**Criterion 6**
**Write concisely and directly, using active voice.**
**Distinguished**
Writes concisely and directly. Conveys precise and unequivocal meaning through clear and consistent use of active voice.
**Proficient**
Writes concisely and directly, using active voice.
**Basic**
Writes passively, with a tendency toward wordiness.
**Non Performance**
Does not write concisely and directly, using active voice.
**Criterion 7**
**Apply APA formatting to in-text citations and references.**
**Distinguished**
Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
**Proficient**
Applies APA formatting to in-text citations and references.
**Basic**
Applies APA formatting to in-text citations and references incorrectly and/or inconsistently, detracting noticeably from good scholarship.
**Non Performance**
Does not apply APA formatting to in-text citations and references.
**## Capstone_Assessment4.docx**
Diabetes Management: A Nurse-Led Family-Centered Intervention
Quincy Kimani
Capella University
Capstone Project
Amanda De La Serna
9/18/2025
## Introduction
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder that presents significant challenges to patients, families, and healthcare systems. In families where multiple members are diagnosed with T2DM, management becomes complex due to the cumulative burden of medication adherence, lifestyle modification, and psychosocial stressors. This project focuses on diabetes management within a family system, recognizing that family engagement and education are central to effective disease control. The problem is highly relevant to nursing practice because nurses play pivotal roles as educators, coordinators, and advocates for holistic, evidence-based care.
## Proposed Intervention
The proposed intervention is a nurse-led, family-centered diabetes self-management education and support (DSMES) program. The intervention integrates telehealth technology, continuous glucose monitoring (CGM), and community-based resources to strengthen adherence and improve outcomes. A teaching plan will be used as the professional product, focusing on family education about diet, medication adherence, lifestyle change, and use of digital tools for monitoring. Nurse facilitators will conduct structured telehealth sessions to guide the family, provide culturally tailored education, and foster collaborative goal-setting.
## Role of Leadership and Change Management
Nurse leadership is essential in mobilizing families and care teams toward improved diabetes outcomes. By applying Lewin’s Change Theory, the intervention emphasizes unfreezing current behaviors, moving toward new lifestyle patterns, and refreezing sustainable self-management practices. Nursing ethics also inform this intervention by ensuring respect for autonomy, justice in equitable access to resources, and beneficence through promotion of well-being. Leaders will encourage shared decision-making, while motivational interviewing techniques will be used to overcome resistance to change within families.
## Communication and Collaboration Strategies
The intervention identifies the family unit as the primary patient group. Effective communication and collaboration are necessary to ensure consistent adherence to care plans. Gathering input from each family member fosters ownership and strengthens natural support systems. Best practices supported by literature include the use of motivational interviewing, culturally sensitive education, and structured family meetings to establish shared goals. Collaboration among nurses, dietitians, primary care providers, and community health workers will enhance continuity of care and prevent fragmentation.
## Policy and Nursing Standards
The intervention is guided by the 2022 National Standards for DSMES and the American Diabetes Association (ADA) 2025 Standards of Care. These emphasize patient-centered, team-based approaches and the integration of social determinants of health in diabetes care. Scope-of-practice policies that empower advanced practice nurses to lead educational and coordination efforts further support this model. Research demonstrates that DSMES and nurse-led models significantly improve glycemic outcomes, reduce complications, and increase patient satisfaction.
## Impact on Quality, Safety, and Costs
The proposed intervention will enhance quality of care by empowering families with the knowledge and skills to self-manage diabetes. Patient safety is prioritized through the use of CGM and telehealth monitoring, which help prevent episodes of hypo- and hyperglycemia. By reducing hospital readmissions and emergency visits, the program is expected to lower costs for both families and the healthcare system. Benchmark data from ADA and CDC reports support that DSMES reduces complications and improves long-term cost-effectiveness.
## Technology, Care Coordination, and Community Resources
Technology plays a central role in this intervention. Telehealth platforms will provide remote education and follow-up, while mobile health applications and CGMs will allow real-time monitoring of glucose levels. Care coordination will involve linking patients to dietitians, primary care providers, and community health workers to promote continuity. Community resources, including diabetes support groups and nutrition classes, will supplement clinical care and address psychosocial needs. Evidence shows that integration of technology, coordinated care, and community-based supports improves self-management, satisfaction, and clinical outcomes.
## Conclusion
Diabetes management in families affected by T2DM requires holistic, evidence-based strategies that incorporate technology, policy, and community resources. The nurse-led, family-centered DSMES program described here addresses these needs by empowering patients and families, improving safety, and reducing costs. By leveraging leadership, collaboration, and change management strategies, this intervention is poised to improve both short-term and long-term outcomes, and is submitted for faculty review and approval as part of the capstone project.
## References
American Diabetes Association. (2025). Improving care and promoting health in populations: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S14–S26. https://doi.org/10.2337/dc25-S001
Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., … & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. Diabetes Care, 45(2), 484–494. https://doi.org/10.2337/dc21-2396
Dailah, H. G. (2024). The influence of nurse-led interventions on diseases management in patients with diabetes mellitus: A narrative review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352
Johnson, C., Ingraham, M. K., Stafford, S. R., & Guilamo-Ramos, V. (2024). Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nursing Outlook, 72(4), 102191. https://doi.org/10.1016/j.outlook.2024.102191
Macedo, V. L. M. D., Sousa, N. P. D., Santos, A. C. D., Santos, W., Stival, M. M., & Rehem, T. C. M. S. B. (2025). Coordination of care in health systems for users with diabetes and hypertension: A scoping review. Revista Latino-Americana de Enfermagem, 33, e4428. https://doi.org/10.1590/1518-8345.7198.4428
Busebaia, T. J. A., Thompson, J., Fairbrother, H., & Ali, P. (2023). The role of family in supporting adherence to diabetes self-care management practices: An umbrella review. Journal of Advanced Nursing, 79(10), 3652–3677. https://doi.org/10.1111/jan.15689
**## capstoneassignment4.docx**
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.
Expand All
**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**: As you revise your writing, check out the resources listed on the Writing Center's
[Writing Support](https://campustools.capella.edu/redirect.aspx?linkid=4646) page.
**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.
**Additional Requirements**
·
**Format**: Format the written analysis of your intervention using APA style.
[APA Style Paper Tutorial [DOCX]](https://campustools.capella.edu/redirect.aspx?linkid=4243) is provided to help you in writing and formatting your paper. Be sure to include:
· A title page and reference page. An abstract is not required.
· Appropriate section headings.
·
**Length**: Your paper should be approximately 5–7 pages in length, not including the reference page.
·
**Supporting evidence**: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.
·
**Proofreading**: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance.
**Portfolio Prompt**: Save your intervention to your
[ePortfolio](https://campustools.capella.edu/redirect.aspx?linkid=1688). After you complete your program, you may want to consider leveraging your portfolio as part of a job search or other demonstration of your academic and professional competencies.
**Competencies Measured**
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
· Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.
· Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care.
· Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
· Competency 4: Apply health information and patient care technology to improve patient and systems outcomes.
· Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
· Competency 5: Analyze the impact of health policy on quality and cost of care.
· Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
· Competency 6: Collaborate interprofessionally to improve patient and population outcomes.
· Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
· Competency 8: Integrate professional standards and values into practice.
· Write concisely and directly, using active voice.
· Apply APA formatting to in-text citations and references.
Please submit both your solution/intervention and the 5–7 page analysis to complete Assessment 4.
**Scoring Guide**
Use the scoring guide to understand how your assessment will be evaluated.
Expand All
**Criterion 1**
**Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.**
**Distinguished**
Defines the role of leadership and change management in addressing a patient, family, or population health problem. Provides an articulate, cogent explanation of the influence that leadership strategies, change management strategies, and nursing ethics had on the development of an intervention and includes a copy of the intervention/solution/professional product.
**Proficient**
Defines the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of the intervention/solution/professional product.
**Basic**
Attempts to describe leadership and change management strategies, and/or does not include a copy of the intervention/solution/professional product.
**Non Performance**
Does not describe leadership and change management strategies, and does not include a copy of the intervention/solution/professional product.
**Criterion 2**
**Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.**
**Distinguished**
Proposes clear, best-practice strategies, well-supported in the literature, for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem. Presents a strong case for the benefits of obtaining input from a patient, family, or group.
**Proficient**
Proposes strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
**Basic**
Attempts to describe communication and collaboration strategies.
**Non Performance**
Does not describe communication and collaboration strategies.
**Criterion 3**
**Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.**
**Distinguished**
Provides an articulate, cogent explanation of how specific state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention. Describes credible research on the effectiveness of these standards and/or policies in improving outcomes.
**Proficient**
Explains how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Basic**
Attempts to explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Non Performance**
Does not describe state board nursing practice standards and/or organizational or governmental policies applicable to the development of a proposed intervention.
**Criterion 4**
**Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.**
**Distinguished**
Provides an articulate, cogent explanation of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Conclusions are well-supported by credible evidence. Cites specific, relevant, and available sources of benchmark data.
**Proficient**
Explains how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Basic**
Provides an explanation, dependent upon unsubstantiated assumptions, of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Non Performance**
Does not explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Criterion 5**
**Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.**
**Distinguished**
Provides an articulate, cogent explanation of how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem. Conclusions are well-supported by specific, credible evidence.
**Proficient**
Explains how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
**Basic**
Attempts to explain how technology, care coordination, and community resources can be applied in addressing a patient, family, or population health problem.
**Non Performance**
Does not describe technology, care coordination, and community resources that can be applied in addressing a patient, family, or population health problem.
**Criterion 6**
**Write concisely and directly, using active voice.**
**Distinguished**
Writes concisely and directly. Conveys precise and unequivocal meaning through clear and consistent use of active voice.
**Proficient**
Writes concisely and directly, using active voice.
**Basic**
Writes passively, with a tendency toward wordiness.
**Non Performance**
Does not write concisely and directly, using active voice.
**Criterion 7**
**Apply APA formatting to in-text citations and references.**
**Distinguished**
Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
**Proficient**
Applies APA formatting to in-text citations and references.
**Basic**
Applies APA formatting to in-text citations and references incorrectly and/or inconsistently, detracting noticeably from good scholarship.
**Non Performance**
Does not apply APA formatting to in-text citations and references.
**## Capstone_Assessment4.docx**
Diabetes Management: A Nurse-Led Family-Centered Intervention
Quincy Kimani
Capella University
Capstone Project
Amanda De La Serna
9/18/2025
## Introduction
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder that presents significant challenges to patients, families, and healthcare systems. In families where multiple members are diagnosed with T2DM, management becomes complex due to the cumulative burden of medication adherence, lifestyle modification, and psychosocial stressors. This project focuses on diabetes management within a family system, recognizing that family engagement and education are central to effective disease control. The problem is highly relevant to nursing practice because nurses play pivotal roles as educators, coordinators, and advocates for holistic, evidence-based care.
## Proposed Intervention
The proposed intervention is a nurse-led, family-centered diabetes self-management education and support (DSMES) program. The intervention integrates telehealth technology, continuous glucose monitoring (CGM), and community-based resources to strengthen adherence and improve outcomes. A teaching plan will be used as the professional product, focusing on family education about diet, medication adherence, lifestyle change, and use of digital tools for monitoring. Nurse facilitators will conduct structured telehealth sessions to guide the family, provide culturally tailored education, and foster collaborative goal-setting.
## Role of Leadership and Change Management
Nurse leadership is essential in mobilizing families and care teams toward improved diabetes outcomes. By applying Lewin’s Change Theory, the intervention emphasizes unfreezing current behaviors, moving toward new lifestyle patterns, and refreezing sustainable self-management practices. Nursing ethics also inform this intervention by ensuring respect for autonomy, justice in equitable access to resources, and beneficence through promotion of well-being. Leaders will encourage shared decision-making, while motivational interviewing techniques will be used to overcome resistance to change within families.
## Communication and Collaboration Strategies
The intervention identifies the family unit as the primary patient group. Effective communication and collaboration are necessary to ensure consistent adherence to care plans. Gathering input from each family member fosters ownership and strengthens natural support systems. Best practices supported by literature include the use of motivational interviewing, culturally sensitive education, and structured family meetings to establish shared goals. Collaboration among nurses, dietitians, primary care providers, and community health workers will enhance continuity of care and prevent fragmentation.
## Policy and Nursing Standards
The intervention is guided by the 2022 National Standards for DSMES and the American Diabetes Association (ADA) 2025 Standards of Care. These emphasize patient-centered, team-based approaches and the integration of social determinants of health in diabetes care. Scope-of-practice policies that empower advanced practice nurses to lead educational and coordination efforts further support this model. Research demonstrates that DSMES and nurse-led models significantly improve glycemic outcomes, reduce complications, and increase patient satisfaction.
## Impact on Quality, Safety, and Costs
The proposed intervention will enhance quality of care by empowering families with the knowledge and skills to self-manage diabetes. Patient safety is prioritized through the use of CGM and telehealth monitoring, which help prevent episodes of hypo- and hyperglycemia. By reducing hospital readmissions and emergency visits, the program is expected to lower costs for both families and the healthcare system. Benchmark data from ADA and CDC reports support that DSMES reduces complications and improves long-term cost-effectiveness.
## Technology, Care Coordination, and Community Resources
Technology plays a central role in this intervention. Telehealth platforms will provide remote education and follow-up, while mobile health applications and CGMs will allow real-time monitoring of glucose levels. Care coordination will involve linking patients to dietitians, primary care providers, and community health workers to promote continuity. Community resources, including diabetes support groups and nutrition classes, will supplement clinical care and address psychosocial needs. Evidence shows that integration of technology, coordinated care, and community-based supports improves self-management, satisfaction, and clinical outcomes.
## Conclusion
Diabetes management in families affected by T2DM requires holistic, evidence-based strategies that incorporate technology, policy, and community resources. The nurse-led, family-centered DSMES program described here addresses these needs by empowering patients and families, improving safety, and reducing costs. By leveraging leadership, collaboration, and change management strategies, this intervention is poised to improve both short-term and long-term outcomes, and is submitted for faculty review and approval as part of the capstone project.
## References
American Diabetes Association. (2025). Improving care and promoting health in populations: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S14–S26. https://doi.org/10.2337/dc25-S001
Davis, J., Fischl, A. H., Beck, J., Browning, L., Carter, A., Condon, J. E., … & Villalobos, S. (2022). 2022 National standards for diabetes self-management education and support. Diabetes Care, 45(2), 484–494. https://doi.org/10.2337/dc21-2396
Dailah, H. G. (2024). The influence of nurse-led interventions on diseases management in patients with diabetes mellitus: A narrative review. Healthcare, 12(3), 352. https://doi.org/10.3390/healthcare12030352
Johnson, C., Ingraham, M. K., Stafford, S. R., & Guilamo-Ramos, V. (2024). Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid. Nursing Outlook, 72(4), 102191. https://doi.org/10.1016/j.outlook.2024.102191
Macedo, V. L. M. D., Sousa, N. P. D., Santos, A. C. D., Santos, W., Stival, M. M., & Rehem, T. C. M. S. B. (2025). Coordination of care in health systems for users with diabetes and hypertension: A scoping review. Revista Latino-Americana de Enfermagem, 33, e4428. https://doi.org/10.1590/1518-8345.7198.4428
Busebaia, T. J. A., Thompson, J., Fairbrother, H., & Ali, P. (2023). The role of family in supporting adherence to diabetes self-care management practices: An umbrella review. Journal of Advanced Nursing, 79(10), 3652–3677. https://doi.org/10.1111/jan.15689
**## capstoneassignment4.docx**
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.
Expand All
**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**: As you revise your writing, check out the resources listed on the Writing Center's
[Writing Support](https://campustools.capella.edu/redirect.aspx?linkid=4646) page.
**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.
**Additional Requirements**
·
**Format**: Format the written analysis of your intervention using APA style.
[APA Style Paper Tutorial [DOCX]](https://campustools.capella.edu/redirect.aspx?linkid=4243) is provided to help you in writing and formatting your paper. Be sure to include:
· A title page and reference page. An abstract is not required.
· Appropriate section headings.
·
**Length**: Your paper should be approximately 5–7 pages in length, not including the reference page.
·
**Supporting evidence**: Cite at least five sources of scholarly or professional evidence that support your central ideas. Resources should be no more than five years old. Provide in-text citations and references in APA format.
·
**Proofreading**: Proofread your paper, before you submit it, to minimize errors that could distract readers and make it more difficult for them to focus on its substance.
**Portfolio Prompt**: Save your intervention to your
[ePortfolio](https://campustools.capella.edu/redirect.aspx?linkid=1688). After you complete your program, you may want to consider leveraging your portfolio as part of a job search or other demonstration of your academic and professional competencies.
**Competencies Measured**
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
· Competency 1: Lead people and processes to improve patient, systems, and population outcomes.
· Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.
· Competency 3: Transform processes to improve quality, enhance patient safety, and reduce the cost of care.
· Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
· Competency 4: Apply health information and patient care technology to improve patient and systems outcomes.
· Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
· Competency 5: Analyze the impact of health policy on quality and cost of care.
· Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
· Competency 6: Collaborate interprofessionally to improve patient and population outcomes.
· Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
· Competency 8: Integrate professional standards and values into practice.
· Write concisely and directly, using active voice.
· Apply APA formatting to in-text citations and references.
Please submit both your solution/intervention and the 5–7 page analysis to complete Assessment 4.
**Scoring Guide**
Use the scoring guide to understand how your assessment will be evaluated.
Expand All
**Criterion 1**
**Define the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of intervention/solution/professional product.**
**Distinguished**
Defines the role of leadership and change management in addressing a patient, family, or population health problem. Provides an articulate, cogent explanation of the influence that leadership strategies, change management strategies, and nursing ethics had on the development of an intervention and includes a copy of the intervention/solution/professional product.
**Proficient**
Defines the role of leadership and change management in addressing a patient, family, or population health problem and includes a copy of the intervention/solution/professional product.
**Basic**
Attempts to describe leadership and change management strategies, and/or does not include a copy of the intervention/solution/professional product.
**Non Performance**
Does not describe leadership and change management strategies, and does not include a copy of the intervention/solution/professional product.
**Criterion 2**
**Propose strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.**
**Distinguished**
Proposes clear, best-practice strategies, well-supported in the literature, for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem. Presents a strong case for the benefits of obtaining input from a patient, family, or group.
**Proficient**
Proposes strategies for communicating and collaborating with a patient, family, or group to improve outcomes associated with a patient, family, or population health problem.
**Basic**
Attempts to describe communication and collaboration strategies.
**Non Performance**
Does not describe communication and collaboration strategies.
**Criterion 3**
**Explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.**
**Distinguished**
Provides an articulate, cogent explanation of how specific state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention. Describes credible research on the effectiveness of these standards and/or policies in improving outcomes.
**Proficient**
Explains how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Basic**
Attempts to explain how state board nursing practice standards and/or organizational or governmental policies guided the development of a proposed intervention.
**Non Performance**
Does not describe state board nursing practice standards and/or organizational or governmental policies applicable to the development of a proposed intervention.
**Criterion 4**
**Explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.**
**Distinguished**
Provides an articulate, cogent explanation of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Conclusions are well-supported by credible evidence. Cites specific, relevant, and available sources of benchmark data.
**Proficient**
Explains how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Basic**
Provides an explanation, dependent upon unsubstantiated assumptions, of how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Non Performance**
Does not explain how a proposed intervention to address a patient, family, or population health problem will improve the quality of care, enhance patient safety, and reduce costs to the system and individual.
**Criterion 5**
**Explain how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.**
**Distinguished**
Provides an articulate, cogent explanation of how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem. Conclusions are well-supported by specific, credible evidence.
**Proficient**
Explains how technology, care coordination, and the utilization of community resources can be applied in addressing a patient, family, or population health problem.
**Basic**
Attempts to explain how technology, care coordination, and community resources can be applied in addressing a patient, family, or population health problem.
**Non Performance**
Does not describe technology, care coordination, and community resources that can be applied in addressing a patient, family, or population health problem.
**Criterion 6**
**Write concisely and directly, using active voice.**
**Distinguished**
Writes concisely and directly. Conveys precise and unequivocal meaning through clear and consistent use of active voice.
**Proficient**
Writes concisely and directly, using active voice.
**Basic**
Writes passively, with a tendency toward wordiness.
**Non Performance**
Does not write concisely and directly, using active voice.
**Criterion 7**
**Apply APA formatting to in-text citations and references.**
**Distinguished**
Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
**Proficient**
Applies APA formatting to in-text citations and references.
**Basic**
Applies APA formatting to in-text citations and references incorrectly and/or inconsistently, detracting noticeably from good scholarship.
**Non Performance**
Does not apply APA formatting to in-text citations and references.
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