By

RTYYUUUIII

A Project

Submitted to the Faculty of D’Youville

Division of Academic Affairs

In partial fulfillment of the requirements for the degree of

Master of Science in Nursing

Buffalo, NY

[February 03, 2023]

Copyright © 2023 by ERTTYYYY. All rights reserved. No part of this project may be copied or reproduced in any form or by any means without the written permission of TYUIOLKJJJJ.

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Name:
__ ________Dr. UUUUUUUU_____________________

Signature: ___________________________________________

Discipline:
________________Nursing________________

Project Defended

On

[February 03, 2023]

Abstract

Obesity has become a significant concern in the healthcare system, and diet is the key contributing factor to obesity. Therefore, a healthy diet should be the primary requirement for reducing weight and improving overall health. The health life knowledge gap among patients and limited nursing education programs contribute to this condition. Nurses should collaborate closely with patients to provide healthcare education that will assist patients in improving their nutritional habits and identify the challenges they face in maintaining a healthy diet. An educational training program for nurses regarding obesity and diet will allow nurses to advance their knowledge of the risk factors of obesity, the health conditions associated with obesity, and how to manage obesity (Seger, 2019). Peplau’s Interpersonal Relations in Nursing Theory was utilized as the theoretical framework for this project. Five content experts reviewed the educational training program for content validity.

Table of Contents

Chapter

I. PROJECT INTRODUCTION …………………………………………………………… 7

Statement of Purpose ……………………………………………………………………….. 8

Theoretical Framework ……………………………………………………………………. 8

Initial Review of the Literature ………………………………………………………….12

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

Project Objectives ……………………………………………………………………………20

Definition of Terms ……………………………………………………………………….. 20

Project Limitations ………………………………………………………………………… 21

Project Development Plan ………………………………………………………………. 22

Plan for Protection of Human Subjects …………………………………………….. 22

Plan for Project Evaluation……………………………………………………………… 23

Summary ……………………………………………………………………………………… 24

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 ……………………………………………………………………………………. 27

Appendices …………………………………………………………………………………… 32

Appendix

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

…………………….….

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

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

D Educational Training Program …………………………………………………………

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

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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 (Balani et al., 2019).

One of the main factors that make successful result in patient with obesity is reversal patient recovery program which includes 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 (Ross et al., 2019).

Hildegard Peplau’s (1991)
Interpersonal Relations in Nursing Theory is utilized as the theoretical framework for developing this project. A brief overview of the theory is presented as well as a discussion regarding how the theory was utilized to guide the development of the project. In addition, Peplau’s (1991) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definitions for nursing’s four metaparadigm concepts will be presented.

Interpersonal Relations in Nursing Theory

Hildegard E. Peplau’s impact on nursing and patient care is reflected in her development and establishment of the Interpersonal Relations Theory. Her theory development began with questions of the philosophical underpinning of psychology as fundamental in-patient care especially when it came to nursing and patient relationships (Peplau, 1991). According to Peplau (1991), the development of patient care begins by understanding the foundational elements as concepts of nursing care. namely, the
orientation, identification, exploitation, and
resolution defined. In her book,
Interpersonal Relations in Nursing, 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.
Orientation refers to the reaction of the patient and the difference from one to another with consideration to resolve in treatment difficulty.
Exploitation on the other hand is the ability of the patient to recognize interpersonal relationships and use the services offered effectively. Lastly, there is a resolution that refers to the relinquishing of ties in the relationship as the patient utilizes the lesson learned to better manage their health (Peplau, 1991).

As a mother of nursing psychiatry, Peplau (1991) 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, 1991). 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 (1991) explains that effective patient outcome delivery comes from trust in diagnostics and thus acceptance of health as an essential metaparadigm aspect. The theory focuses on developing the relationship between a nurse and a patient to emphasize trust and collaboration.

Based on Peplau (1991), the experience of establishing a connection between a nurse and a patient is an indicator of progress reporting and is the only source of data for patient experience information. Perception of the phenomena of patient information as instrumental to positive is highlighted as a primary measure of the direction of health. Based on the fact that health is described to be only a success when it moves in the positive direction, by looking at the patient with obesity this means loss of weight. At the same time, with the insistence on the sustainability of better health as the result being sought, there is direct evidence that the management of health, in the long run, is the better outcome for the patient in this project.

Peplau (1991) is supported by her in-depth analysis of the achievability of better health through utilitarian task alignment. Using communication as the necessary tool for the nurse to ensure that a patient attains a favorable outcome, as a theory, Interpersonal Relations in Nursing Theory emphasizes the built-in interaction as a psychodynamic need. This need is important as it is directionally focused on relieving the patient’s anxiety and improving their confidence regardless of external and self-perceived variables. Centralization of goal setting for a patient with obesity is linked directly to the strengthening of the nurse-patient relationship as the best approach to attaining better health outcomes.

This theory is a perfect fit for this project as the relationship between the nurse and patient must be founded on trust so that information can be shared comfortably and with trusted support from nurses. A support system must be developed because obesity and the issues surrounding obesity may lead to decreased self-esteem and mental health issues. 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.

Interpersonal Relations in Nursing Theory explains it as an input for developing positive outcomes and relinquishing the relationship with a support system that enhances positive outcomes Peplau (1991) . It is the promotion of 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.

As such, following Peplau’s underpinning of outpatient care for obese patients is ensuring that patient that individual preconceptions and mutual understanding of the nature of a medical issue allow for better collaboration toward a productive solution.

Literature Synopsis

The literature review has revealed that obesity is a significant health crisis globally, with more than two-thirds of the adults in the United State of American are considered to be overweight or obese. As a result, most authors stress the need for vigilance in dealing with the health crisis, including improving the outpatient setting; this intervention will facilitate the management of the initial stages of the disease, preventing its escalation and the emergence of associated comorbidities. In addition, the literature review discovered a link between obesity and the development of advanced heart diseases. The role of nursing is to provide integrated care and enhance patient comfort by providing interventions to alleviate symptoms of obesity and encourage a healthy diet, which can be facilitated by nurses providing pertinent information. The high number of obesity cases risks the population’s future health and would create enormous pressure on the available health resources. Therefore, there is a need for training in this area to counteract the health effects.

Furthermore, the review highlights the importance of a nurse-patient relationship, a healthy diet, diabetes and obesity teaching, and health literacy. Health literacy is an integral part of the nursing fraternity; it allows patients to have the opportunity to understand the implication of obesity in the long run. The cost of health, care expenditures, and hospitalization risks can motivate outpatients to adhere to their plan for losing weight. This educational training program suggests that health literacy is essential for weight loss and health maintenance. Creating personalized and participatory lifestyle change plans through a provider-patient relationship that conforms to the objectives and recognizes mental health is possible; this caters to incorporating strategies that align outcomes centered on the totality of patient care within the six sigma of quality improvement in healthcare delivery.

The review identified the importance of healthcare providers and outpatients collaborating to sensitize patients on environmental awareness, recognize the appropriateness of the environment for supporting weight management, providing education on a healthy diet, and create a carefully defined plan with the patient to understand the expected health outcomes. Furthermore, the literature review emphasizes that preventive healthcare is essential in enhancing the efficiency of care and resulting in better outcomes. Education on a healthy diet and obesity for nurses will serve as an opportunity for integration of transformative learning strategies, improvement on patient care outcomes, increasing professionalism, and improvement health and wellness outcomes. Therefore, transitioning patients from outpatient to preventive healthcare would significantly reduce morbidity and mortality rates among patients. Overall, the review highlights the significance of nursing education in providing integrated care and promoting healthcare delivery as a focal point in preventive care.

Project Objectives

The objectives of this project are to:

1. Conduct an extensive review of the literature exploring a healthy diet 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 2018 to 2023, 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, and Google Scholar.

2. Develop an Educational Training Program; and

Definition of Terms

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

Health Promotion

Theoretical Definition: Facilitation of motivational behavior to recognize a positive outcome as an approach to better health management (Peplau, 1991).

Operational Definition: conducting and directing the implementation of weight management strategies that enhance forward-focused change for a better quality of life for outpatients that are diagnosed with obesity.

Healthcare Support

Theoretical and Operational Definition: integrative healthcare service delivery that facilitates the provision of effective and efficient aid to the patient in a way that is essential to their safety, improved quality of life, and development of better coping tools (Maciejewski et al., 2019). Operational Definition: A nursing duty that recognizes the provision of the totality of care for outpatients with obesity through readiness in resource and information availability that allows sustainable improvement of patient’s health.

Healthy diet

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). 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 and overweight patients.

Limitations

The Project Author recognizes the following project limitations:

1. The implementation of the educational training program is not within the context of this project;

2. The educational training program is developed in the English language only and may benefit a more culturally diverse population if written in additional languages.

Project Development Plan

Plan for the Protection of Human Subjects

Following approval from D’Youville Patricia H. Garman School of Nursing, the graduate faculty designee (Appendix A) five professionals with knowledge and expertise in the area of a healthy diet for patients with obesity will be personally approached and asked to voluntarily participate as content experts in the review and evaluation of an educational training program (Appendix D). Content experts will be advised that participation or non-participation as expert reviewers will have no effect on their employment status. The Project Author has a collegial, professional, and nonsupervisory 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 for a period of three years and then destroyed.

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 educational training program (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 six 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 educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. Approximately 20 minutes will be required to review the resource guide and to complete the Content Expert Project Evaluation Tool. Content experts will be given seven 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 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.

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

the development of an educational training program for nurses in an outpatient setting exploring healthy diets for patients with obesity, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II will provide an extensive review of the literature focusing on an educational training program for nurses regarding the importance of a healthy diet for patients with obesity and a chapter summary. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future projects and research, and a chapter summary.

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. 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 points 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 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 studies by Smith et al. 2020. 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 agrees on goals, share a vision of improvement in general metabolic health status, the patient and provider will be able to create a personalized and participatory lifestyle changes 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) points 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; 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 project 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, the value must be provided in educating the patient on the potential risks they face within 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 perspective of the community and support system of the patient 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.

According to Hee Soon, et al. (2019) opted to conduct a study on this subject focusing on the younger populations. They point out that one thing that tends to be overlooked is the fact that children tend to learn from what they see happening in their surroundings. Thus, even if a child is prone to eating healthy when they are in their respective homes, they are also prone to be influenced by what they see in schools or other surroundings. This research study aimed to answering the question, “What are the barriers at home and school to healthy eating?” 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 that when it comes to the management of unvoiced expectations of a patient in a way that recognizes their efforts and input towards 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 (Maciejewski et al., 2019). 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, Wharton et al. (2020), tackles nursing and obesity pointing it to be one of the current health concerns affecting a large proportion of the world’s population as it interferes with health outcomes. 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).

Reinforcing Positive Environment in Nurse-Patient Relationship

When looking at the studies, it is evident that nurse and patient relationships are integral to both the definition of health and the understanding of treatment planning. These are essential to the pathways to positive outcome expectation and hence accurate to the operational definitions. Given that outpatient care for obesity is almost therapeutic, there is a sense of delivery requiring that verbal and non-verbal communication be read. As such, the nurse must have the core conditioning of genuine concerns, which sometimes could be perceived as going above and beyond the baseline required (Okdie & Ewoldsen, 2018). The relationship between the two is skill-based, examining the level of trust in both directions with absolute truths. The points of conflict should thus be handled with care and isolated from the goals by accepting attitudes as progression hence the removal of fear (Walia et al., 2022). This also removes the anxiety of either side as the nurse can trust that discipline will be employed within the period they have not met. Similarly, the patient will trust that information will not be withheld, anger will not be enforced, and the environment of care will be positively reinforced with empathy rather than pity.

Chapter II presented a review of the recognition of nurses’ efforts in collaboration with outpatients by sensitization on personal and environmental awareness as essential in all round wellness. The chapter details the importance of trust and unique relationships from one patient to another in ensuring the totality of care. Furthermore, it presents strategies that align outcomes centered on the totality of patient care within the six sigma of quality improvement in healthcare delivery. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future 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, 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.

Bloor, M., & McIntosh, J. (2019). Surveillance and concealment: a comparison of techniques of client resistance in therapeutic communities and health visiting. In 
Selected Writings in Medical Sociological Research, 93–116. Routledge.

Bucher, D. T. S., Courvoisier, D. S., Saldarriaga, A., Martin, X. E., & Farpour‐Lambert, N. J. (2018). Training is essential in nurses’ and physicians’ knowledge, attitudes, representations, and declared practices about obesity in a university hospital.
Clinical obesity, 
8(2), 122-130.

Chae, D., & Park, Y. (2019). Organizational cultural competence needed to care for foreign patients: A focus on nursing management.
Journal of Nursing Management, 
27(1), 197–206.

Shi, H. (2017). Planning Effective Educational Programs for Adult Learners. 
World Journal of Education, 
7(3), 79–83.

Smith, J. D., Fu, E., & Kobayashi, M. A. (2020). Prevention and management of childhood obesity and its psychological and health comorbidities. 
Annual review of clinical psychology, 
16, 351-378.

Srivastava, G., Fox, C. K., Kelly, A. S., Jastreboff, A. M., Browne, A. F., Browne, N. T., … & Apovian, C. M. (2019). Clinical considerations regarding the use of obesity pharmacotherapy in adolescents with obesity. 
Obesity, 
27(2), 190–204.

Stonerock, G. L., & Blumenthal, J. A. (2017). Role of counseling to promote adherence in healthy lifestyle medicine: strategies to improve exercise adherence and enhance physical activity. 
Progress in cardiovascular diseases, 
59(5), 455-462.

Tartavoulle, T., & Landry, J. (2021). Educating Nursing Students About Delivering Culturally Sensitive Care to Lesbian, Gay, Bisexual, Transgender, Questioning/Queer, Intersex, Plus Patients: The Impact of an Advocacy Program on Knowledge and Attitudes.
Nursing education perspectives, 42(4), E15-E19.

Turner, M., Jannah, N., Kahan, S., Gallagher, C., & Dietz, W. (2018). Current knowledge of obesity treatment guidelines by health care professionals. 
Obesity, 
26(4), 665–671.

Walia, I., Krainovich-Miller, B., & Djukic, M. (2022). Nurses’ Lived Experience with Nurse–Physician Collaboration. 
The Journal of Continuing Education in Nursing, 
53(9), 397–403.

Appendix D

Educational Training Program

Appendix E

Survey Tool Results

Without leadership training, CNs cannot grow as frontline leaders and integrate TL strategies, and this has been shown to negatively impact patient care outcomes and impact job satisfaction and retention rates. The CN is the most accessible and present leader at the bedside and frontline. CNs spend their entire shifts managing competing demands, while providing undertaking patient assignments in most cases. This contributes to role ambiguity and is a barrier to undertaking TL strategies to be effective leaders. Therefore, their ability to effectively lead and communicate within their units and organizations is compromised. This is a matter that requires due attention towards addressing deficiencies within the current healthcare system and building stronger frontline leaders in the future.

The nursing landscape is undergoing significant changes with record number of nurses leaving the profession due to burnout and the current global pandemic. Skill development in communication is a strategy to contribute to the leadership capabilities of CNs. Providing them with necessary skills such as communication is central to their leadership development and ability to do their jobs. When they are provided the tools to succeed and work within an environment that is empowering, this increases job satisfaction and retention of CNs and those that work with them.

Significance and Justification

Findings from the initial literature review revealed a lack of knowledge exists in nursing and patient care practice regarding the leadership development of CNs and subsequently integration of TL strategies in their roles. Most of the literature focused on leadership of managers and directors and failed to consider the critical role CNs play to the 24/7 operation of their units. This was supported by Bateman and King (2020) and Dols et al. (2021) identifying CNs as integral to the running of units, coordination of patient care and communication among care teams within the department and across the organization. CNs act as advocates for patients, colleagues, and their work environments and act as a support and resource to staff and patients (Doherty et al., 2021). CNs are well-equipped to integrate TL strategies in their role as frontline leaders. Boamah et al. (2018) found TL had a significant positive direct effect on structural empowerment and this encouraged bedside clinical leadership practices. This in turn had a positive effect on job satisfaction and a direct negative influence on adverse outcomes (Boamah et al., 2018). CNs are the main point of contact for staff with immediate patient care concerns and thus, should integrate TL strategies in their role as frontline leaders. Therefore, the purpose of this project was significant since it had potential to positively impact leadership development of CNs through integration of TL strategies and as a result, lead to more confident and effective frontline leaders. Furthermore, the lack of literature on CN leadership development is a clear indication for the development of this project as it will allow for further research on the role of

CNs within the healthcare system.

Project Objectives

The objectives of this project were to:

1. Conduct an extensive review of the literature exploring the importance and benefits of integrating transformational leadership strategies for charge nurses using the following keywords both singularly and in multiple combinations: charge nurse, transformational, leadership, front line, nursing, and leader. With the exception of classical works, databases searched, limited to the years 2017 to 2022, included CINAHL complete, [email protected], ScienceDirect, Supplemental Index, PubMed, Gale

Academic OneFile, and Gale General OneFile:

2. Develop an educational training program; and

3. Have a panel of five content experts with extensive knowledge and expertise in recognizing the importance of integrating transformational leadership for charge nurses evaluate and critique the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.

Definition of Terms

The following concepts were defined both theoretically and operationally for the purpose

of this project:

Transformational Leadership

Theoretical Definition: “Leaders…who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions” (Institute of Medicine,

2011, p. 221).

Operational Definition: Leadership where charge nurses work towards gaining knowledge and experience to become effective leaders to support development and growth of themselves and others to meet organizational objectives and advocate for positive change for staff, patients, families, and the organization.

Frontline Leader

Theoretical Definition: “Frontline…leaders direct staff and unit systems while ensuring that quality, safe patient care is provided” (McGarity et al., 2020, p. 1). Frontline leaders refers to nurse managers.

Operational Definition: The frontline leader refers to the charge nurse because they are consistently present at the position of care delivery and support staff. They make and influence decisions to coordinate patient care, staffing considerations and manage the flow of the unit.

Limitations

The Project Author recognized the following project limitations:

1. The implementation of the educational training program was not within the context of this project;

2. The educational training program was developed in the English language only and may benefit a more culturally diverse population if written in additional languages;

Project Development Plan

A detailed topical outline of the educational training program content was created based on the extensive review of evidence-based literature and the theoretical framework used to support and guide the development of the educational training program. After permission was granted from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in recognizing the importance of integrating transformational leadership for charge nurses in a pediatric emergency department were asked if they were interested in voluntarily participating as an expert content reviewer for the educational training program. The content expert panel consisted of three pediatric emergency room charge nurses, one nurse manager, and one hospital administrator. If interested, the Project Author mailed a packet containing a Letter of Intent (Appendix B), a copy of the Content Expert Project Evaluation Tool created by the Project Author specifically for the project (Appendix C), a copy of the educational training program (Appendix D), and a self-addressed stamped envelope. The Letter of Intent explained the project purpose and the instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author. The Content Expert Project Evaluation Tool contained six evaluative items with space for narrative comments and suggestions. Approximately 20 minutes were required to review the educational training program and to complete the Content Expert Project Evaluation Tool. Content experts were provided a self-addressed envelope to return the Content Expert Project Evaluation Tool to the Project Author. Once all evaluation tools were returned to the Project Author, data were analyzed and reported narratively and in bar graph format. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tools were provided to the content expert reviewers by postal mail.

Plan for the Protection of Human Subjects

Following approval from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in the area/field of recognizing the importance of integrating transformational leadership for charge nurses were personally approached and asked to voluntarily participate as a content expert in the review and evaluation of the educational training program (Appendix D). Content experts were advised that participation or non-participation as an expert reviewer will have no effect on their employment status. The Project Author had a collegial, professional, and non-supervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. Content experts were guaranteed confidentiality because identifying characteristics would not be collected on the Content Expert Project Evaluation Tool and because their names would not be revealed anywhere in the project manuscript or in required project presentations. Only the Project Author would know the names of the content expert reviewers. Return of the completed content expert Project Evaluation Tool (Appendix C) would indicate implied voluntary consent to participate as a content expert reviewer. Content experts were 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 would 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 for a period of six years and then destroyed.

Plan for Project Evaluation

After obtaining full approval from the D’Youville Patricia H. Garman School of Nursing (Appendix A), the Project Author mailed 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 explained 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 consisted of six evaluative items scored on a four-point Likert Scale that ranges from (1) Strongly Disagree, (2) Disagree, (3) Agree, and (4) Strongly Agree. Space was provided for narrative comments and suggestions following each evaluative item. Evaluative items asked reviewers to rate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. Approximately 20 minutes were required to review the educational training program and to complete the Content Expert Project Evaluation Tool. Content experts were given seven 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 were presented narratively and displayed in bar graph format. Content expert suggestions and comments were 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 were provided to the content expert reviewers by postal mail.

Summary

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 an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II will provide an extensive review of the literature focusing on an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders and a chapter summary. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future projects and research, and a chapter summary.

Review of the Literature

A review of nursing and health related literature was conducted to explore the importance and benefits of integrating TL strategies for CNs in their role as frontline leaders using the following keywords both singularly and in multiple combinations: charge nurse, transformational, leadership, front line, nursing, and leader. With the exception of classical works, databases searched, limited to the years 2017 to 2022, included CINAHL complete,
[email protected], ScienceDirect, Supplemental Index, PubMed, Gale Academic OneFile, and Gale General OneFile. The search was limited to the years 2017 to 2022 to ensure that current evidence-based literature was reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.

CN Roles, Responsibilities and Role Ambiguity

While CNs are part of the nursing leadership team, they are not always viewed as formal leaders (Weaver et al., 2018). Different organizations have varying structures in place for the CN role. Some have nurses rotate through the role while others have it as a permanent role among a designated group of nurses on the unit (Spiva et al., 2020). Regardless of the organizational structure, the CN role and responsibilities are poorly defined, leading to role ambiguity. CN responsibilities are often learned on the job and their duties vary in some places depending on the presence of the manager (Andronico et al., 2019; Bateman & King, 2020). Absence of clearly defined CN roles, responsibilities, and expectations to address human resource and management issues when the manager is absent contributes to role ambiguity because the lines between leader and management are blurred (Weaver et al., 2018). Managing staffing, assignments, patient care, patient care coordination, team building, staff performance, conflict management and meeting organizational objectives are some of the CN roles and responsibilities (Bateman & King, 2020; Doherty et al., 2021; Dols et al., 2021; Spiva et al., 2020). Due to the level of responsibility and expectations of the CN, this places a heavy burden on prioritizing competing demands of the unit, staff, patients, and organizational objectives during a shift. This greatly limits their ability to engage in leadership participation, engagement, and building and contributes to a lack of clear leadership and supervision which has been identified as a threat to patient safety (Boamah, 2018; Embree et al., 2018). This is supported by Boettcher et al. (2019) who found most CNs take on unassigned duties during their shifts, adversely impacting their ability to effectively lead. Lack of clear CN roles and responsibilities deprioritizes the leadership impact and capability of CNs. Therefore, protected time to develop leadership skills was mentioned by Jones (2020) as essential to CN development. Protected time allows for CN involvement in committees and conferences (Jones, 2020) contributing to their experiences and growth in TL behaviors. In addition, this takes into consideration the 24/7 nature of CN staffing, promotes investment in the CN role and challenges the view of leadership building as an extracurricular activity (Jones,

2020; Spiva et al. 2020).

Lack of Education, Formalized and Standardized Training and Mentorship Impact on CNs

Many studies have cited the lack of formalized and standardized training of CNs prior to entering and while orienting to the role yields CNs without the proper tools and information to lead (Bateman & King, 2020; Bognar et al., 2021; Doherty et al., 2021; Dols et al., 2021; Laut et al., 2018; Teran & Webb, 2016). Accordingly, Jones (2020) and McGarity et al. (2020) found when CN training occurred well before CNs take on the role and while not actively on the job, this facilitated greater uptake of TL strategies. Correspondingly, Shaughnessy et al. (2018) found a positive correlation between TL practices and higher levels of education. Although CNs do not require advanced degrees for their role, the expectations and responsibilities dictate further education is required. Education and formalized and standardized training can increase the TL strategies, resilience, and confidence of CNs. This is supported by findings by Cariaso-Sugay et al. (2021), Dols et al. (2021), Laut et al. (2018) and Spiva et al. (2020), where training was found to increase resilience among CNs and increase their confidence in the role. It is important to consider the importance and value of protected time to be available to CNs to further develop TL skills after entering the role. Jones (2020) and McGarity et al. (2020) reinforced the value of protected time for CN leadership skills development and deemed it essential. Education for CNs must go beyond focus on the task they are expected to complete on their shift. CNs require formalized and standardized training and education on communication, conflict management, managing staff performance and TL strategies to meet demands of their role and objectives of the organization in which they work. CNs are considered expert clinicians and possess foundational leadership skills (Bateman & King, 2020; Boettcher et al., 2019). When they become CNs, they are considered novice; therefore, they need education, training, and mentorship to facilitate their success (Boettcher et al., 2021; Bognar et al., 2021; Doherty et al., 2021; Teran & Webb, 2016). It cannot be stressed enough the importance of ongoing development of CNs and the positive impact it can have on staff, patients, and the organization. Boettcher et al. (2019) and Dols et al. (2021) found mentorship and preceptorship by CNs was found to have a positive impact on nursing-sensitive indicators and improved workflows leading to higher levels of patient care.

Effects of TL by CNs on Patient Care Outcomes and Structural Empowerment

TL has been associated with reduced incidences of adverse patient events because it creates environments where professional nursing practice is supported and promotes better patient outcomes (Boamah, 2018; Boamah et al., 2018; Hudson-Covolo et al., 2018; Teran &

Webb, 2016). Additionally, TL among CNs can improve patient engagement (McGarity et al., 2020) through behaviors such as patient rounding which was found to lead to positive patient outcomes (Hudson-Covolo et al., 2018; Kramer & Davies, 2021). CN TL development has potential to positively impact organizations to deliver high-quality patient care to a growingly complex patient population. Current healthcare systems are disintegrating from demands prior to and during the pandemic. Therefore, TL strategies among CNs is needed to ensure patient care is not impacted and staff are in healthy work environments. Likewise, healthy work environments are achieved when CNs can function in settings that do not hinder their ability to lead (Boamah, 2018). Supportive work environments with policies in place to protect patients and staff safety, functioning medical technology and conducive workflow designs are just some examples of structural empowerment resulting from TL strategies among CNs (Boettcher et al., 2019). As a result, structural empowerment through TL can increase CN confidence in their role to positively impact their teams and organization as reported by Boamah (2018), Cariaso-Sugay et al. (2021), Dols et al. (2021) and Kramer & Davies (2021). TL strategies were found to increase uptake of lean methodology in a study by Boettcher et al. (2019) and subsequently increased CN engagement. The experience and breadth of knowledge of CNs ensures efficient unit flow and operations. Enhancing the CN role through TL strategy integration would support positive patient outcomes, structural empowerment and has potential to positively impact the healthcare system.

CN Influence on Nurse Retention and Job Satisfaction

The projected nursing shortage in Canada and the United States is a cause for concern for many health policy advocates, government critics and unions. The ongoing COVID-19 global pandemic has only exacerbated this issue with growing concern regarding nurse staffing affecting ability of organizations to provide and deliver care safely. Policy makers are at a crucial junction and nurse retention is paramount to a sustainable healthcare system. Studies by AlMajid et al. (2018), Bognar et al. (2021), Dols et al. (2021), Sisk et al. (2021) and Teran and Webb (2016) found CN development within organizations positively impacted nursing retention rates. Particularly, Bognar et al. (2021) found CN mentorship helped with nursing retention. There are many factors causing nurses to leave the workplace and the effect of nursing leadership has been identified as a reason. A study by Laut et al. (2018) identified the effect of the CN on others and lack of support as a factor for new nurses to leave the emergency department. The importance of the CN role was considered by senior nursing leaders in one organization and as a result, a supportive CN model was implemented to specifically address retention (Sisk et al., 2021). Boettcher et al. (2019) and Laut et al. (2021) found positive CN behaviors decreased staff turnover; specifically, among new nurses. In addition to nurse retention, CNs increase job satisfaction in their work environments. It was previously discussed how CN TL positively influences structural empowerment. Positive workspaces lead to job satisfaction among CNs and colleagues as reported by Bognar et al. (2021). CNs work closely with bedside nurses and are involved in patient care coordination of their units. Positive interactions and relationships with colleagues increase perceived levels of support from CNs by staff (Laut et al., 2021). Thus, leading to higher levels of job satisfaction and reduced nursing turnover. Development of TL strategies among CNs enhances their leadership capabilities and has potential to greatly influence nursing retention and job satisfaction among colleagues.

Communication and the CN role

Frontline leaders such as CNs, must possess effective communication skills because they are tasked with coordinating patient care, identifying key issues, and raising awareness amongst senior nursing leaders and managing conflict. Communication is considered essential to the CN role because CNs communicate within their care teams as well as across organizations and is viewed as a trait that makes CNs feel successful (Bateman & King, 2020; Doherty et al., 2021; Embree et al., 2018; Spiva et al., 2020; Teran & Webb, 2016). Communication is a skill requiring ongoing development as noted by Doherty et al., (2021) who found communication to be a challenging area for CNs the longer they remained in the role. In the studies reviewed for this project, simulation, in-class lectures, and online resources were implemented as strategies to enhance development of communication skills for CNs (Bateman & King, 2020; Doherty et al., 2021; Spiva et al., 2020; Teran & Webb, 2016).

Impact of Secondary Traumatic Stress, Compassion Fatigue, Burnout and Resilience on

CNs

As frontline leaders, CNs endure stress from their role, colleagues, and patients. If stress is not effectively managed, this puts CNs at risk for compassion fatigue (CF), secondary traumatic stress (STS) and burnout (Al-Majid et al., 2018). In a study by Kramer and Davies (2021), managing role-related and staff stress was identified as a challenge by CNs. Inability to manage stress affects CN resilience and adversely impacts those around them and their ability to lead. Strategies to address CF, STS and burnout are needed in this group so they can empower staff through TL strategies to deliver high-quality patient care. Therefore, training and education on resilience is needed. A study by Spiva et al. (2020) found higher rates of resilience among CNs after participation in a training program. This supports the need for ongoing recognition, training, and development in CF, STS, and burnout in CNs to ensure experienced leaders are introduced and remain in the role. It is noteworthy, burnout, CF and STS are not limited to novice CNs. Interestingly, a study by Doherty et al. (2021) found the longer CNs stayed in the role, levels of stress grew, and this was associated with level of responsibility expected of them but lack of authority to execute these duties. In the same study, it was found CN confidence to perform increased the longer they stayed in the role (Doherty et al. 2021). This is evident longevity in the CN role requires greater focus on leadership capabilities over task performance. Role confidence alone is not enough because it fails to highlight need for long-term TL development in CNs. Due attention must be paid to occupational hazards of CNs to ensure adequate supports are in place to address CF, STS, and burnout for them to be effective leaders.

CHAPTER III

PROJECT DEVELOPMENT PLAN

Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary.

Project Setting and Population

The intended project setting was the emergency department of a pediatric hospital. The intended project population were charge nurses in the emergency department of a pediatric hospital.

Content Expert Participants

Following approval from D’Youville Patricia H. Garman School of Nursing (Appendix A), five content experts with knowledge and expertise in the role of the charge nurse were contacted by the project author and asked to voluntarily participate in the review of the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The first content expert was a charge nurse in a pediatric emergency department with over 10 years of nursing experience and is currently pursuing a master’s degree in nursing. The second content expert was a charge nurse in a pediatric emergency department with over 10 years of nursing experience and is currently pursuing a master’s degree in nursing. The third content expert was a charge nurse in a pediatric emergency department with over 20 years of nursing experience that includes research, critical care nursing experience and is an instructor for a pediatric emergency nursing course. The fourth content expert was a master’s prepared nurse manager with previous experience as an emergency room charge nurse. The fifth content expert was a hospital administrator with a master’s degree in nursing with previous experience as nurse

manager and director.

Data Collection Methods

The educational training program was developed based on an extensive review of the literature. The student has not developed the educational training program based on feedback from the content experts. The student develops the product and then asks for feedback. Upon receipt of full approval from D’Youville’s Patricia H. Garman School of Nursing (Appendix A), the five content experts were contacted by the Project Author and asked to voluntarily participate in the review and evaluation of the educational training program. All five content experts agreed to participate. A manila envelope containing a recruitment Letter of Interest (Appendix B), one copy of the Content Expert Project Evaluation Tool (Appendix C), one copy of the educational training program (Appendix D), and a stamped self-addressed envelope with instructions on how and when to return the evaluation tool to the Project Author was provided. Content experts were asked to review and evaluate the educational training program for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were instructed not to place any identifying marks on the evaluation tool. Return of the evaluation tool signified implied consent to participate as content experts. Content experts returned the evaluation tool to the Project Author using a self-addressed stamped envelope.

Project Tools

The purpose of this project was to develop an educational training program (Appendix

D). The development of the educational training program was guided by Benner’s Novice to

Expert theory. The educational training program (Appendix D) consisted of transformational leadership strategies to be incorporated in the charge nurse role developed based on findings obtained from the review of current evidence-based literature.

A Content Expert Evaluation Tool (Appendix C) was developed by the Project Author specifically for the purpose of having five content experts with knowledge and expertise in the charge nurse role to evaluate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were asked to rate the six evaluative items using the following four-point Likert Scale: Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). The content experts were instructed to circle one response for each item indicating their appraisal for that particular item. Space was made available immediately following each evaluative item to provide the content experts with opportunity to comment or make further suggestions if needed. Data from the Content Expert Evaluation Tool were collated, analyzed, and presented in narrative and bar graph format. Content expert written comments and suggestions were analyzed for common themes and presented in narrative format.

The Protection of Human Subjects

Following approval from the D’Youville Patricia H. Garman School of Nursing

(Appendix A), five experts with knowledge and expertise in the charge nurse role and benefits of integrating transformational leadership were approached and personally asked to participate as a content expert reviewer for the educational training program developed for the purpose of this project. The Project Author had a collegial, professional, and non-supervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. The content expert participants were advised that participation or non-participation as a content expert reviewer would have no effect on their employment or evaluative status. The participants were guaranteed confidentiality as identifying characteristics would not be displayed on the

Content Expert Evaluation Tool (Appendix C) and all data would be reported in aggregate form. Return of the completed Content Expert Evaluation Tool would indicate implied consent to participate as a content expert. All five content experts were advised that their participation was completely voluntary and that they would not be able to withdraw from project participation once the completed Content Expert Evaluation Tool was returned to the Project Author as there would be no way to identify them. Returned Content Expert Evaluation Forms will be kept in a locked file cabinet drawer located in the Project Author’s home for a period of six years and then destroyed as per IRB protocol.

Summary

Chapter III discussed the intended project setting and population, a detailed description of the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future practice, and recommendations for future projects and research.

CHAPTER IV

PROJECT EVALUATION, IMPLICATIONS, AND FUTURE RECOMMENDATIONS

Chapter IV will discuss the evaluation of the project, implications for future practice, and recommendations for future projects and research.

Project Evaluation

After permission was obtained from the D’Youville Patricia H. Garman School of Nursing (Appendix A), five content experts with knowledge and expertise in the benefits of integrating transformational leadership in the charge nurse role were approached in person and asked to voluntarily review and evaluate the educational training program using a Content Expert Evaluation Tool developed by the Project Author. The Content Expert Evaluation Tool included six items asking content experts to evaluate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were asked to rate the six evaluative items using the following four-point Likert Scale: Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). Space was made available immediately following each item to provide the content experts with opportunity to comment or make further suggestions if needed. Following is a discussion of the results of the content expert evaluation.

The first question on the Content Expert Evaluation Tool asked the content experts if they felt that the questions presented on the educational training program were clear and comprehensible. Three out of the five content experts (60%) agreed that the questions were clear and comprehensible, and one content expert (20%) strongly agree. One content expert (20%) strongly disagreed that the questions were clear and comprehensible.

Question two on the Content Expert Evaluation Tool asked the content experts if they felt that the questions included on the educational training program were presented at an appropriate level of reading for charge nurses. Two out of the five content experts (40%) strongly agreed that the questions were presented at an appropriate level of reading for the intended population and two content experts (40%) agreed. One content expert (20%) disagreed that the questions were presented at an appropriate level of reading for the intended population.

Question three on the Content Expert Evaluation Tool asked the content experts if they felt that the questions included on the educational training program were relevant and fits the project purpose. Three out of the five content experts (60%) strongly agreed that the questions were relevant and fits the project purpose. Two content experts (40%) disagreed that the questions were relevant and fits the project purpose.

Question four on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program is well designed and professionally presented. Three out of the five content experts (60%) agreed the educational training program is well designed and professional presented. Two content experts (40%) disagreed the educational training program is well designed and professional presented.

Question five on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program is logical and well organized. Three out of the five content experts (60%) agreed the educational training program is logical and well organized and two content experts (40%) strongly agreed.

Question six on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence. Four out of the five content experts (80%) strongly agreed the educational training program addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence and one content expert (20%) agreed with this question.

Written comments and suggestions given by the content experts to strengthen the development of the educational training program are summarized as follows with examples. Four content experts commented on the implementation of the educational training program. One content expert wrote “It needs more information on how this can be implemented, how we would actually use the tool. I think it is the training side that needs more depth. It needs some tailoring to be more direct, give some examples and fine tune the teaching portion”. Another content expert wrote, “…The notion of a package to allow for individuals to perform self-reflection is valid for self-awareness and understanding of one’s ways of improving, however as seen in the definition of training, to me as a reviewer does not meet criteria. My initial thought was to receive some type of teaching/learning component (Via, lecture, Zoom Meeting, class, educational link…) to have and expert present, and teach transformation a leadership components, with the implementation of using a theoretical framework (Benner’s Novice to

Expert)…”. A third content expert wrote, “Having the learners perform the same assignment four times is repetitive and the learner may become disengaged and the value in why there are doing it, which is reflecting on their practice, may be lost. (I am not appreciating why this assignment is occurring four times and what type of time frame it is occurring.)”. A fourth content expert wrote. “What happens after all of the examples have been entered? Where does the CN go from there? Is there any follow up?”. The comments of four out of five content experts suggest more clarity on the delivery and implementation of this educational training program is required.

Furthermore, clarifying the purpose and overall goal of the project, setting objectives for participants and providing follow-up are methods to be considered to enhance implementation of the project.

All the content experts commented on the use of transformational leadership in the educational training program and whether clarity is needed for learners of the educational training program. One content expert wrote, “If CNs are pulling from Novice/Advanced Beginner examples, they may not yet possess Transformational Leadership qualities that can be applied to the example. Maybe the first question could be, Which component(s) of TL (if any) is demonstrated in your example?” A second content expert wrote, “The training program is a little abstract, I think having some examples or areas written in your own words might be more helpful. It also depends on the level/years of experience as a leader because younger leaders may not have the experience to reflect on all of these scenarios”. A third content expert wrote, “Possibly providing example of each of the Transformational Leadership styles along with the definition provided. For some learners this may be the first time they are learning about transformation
(sic) leadership as well one tries to find themselves in these theoretical models in order for them to understand how this new knowledge relates to them.” A fourth content expert wrote, “The explanations of TL might include an easy to read summary at the beginning or end of the quotes. Your participants might find the quotes lengthy and have difficulty pulling the most important points out of them. Of course, this would depend on how engaged your audience is. The less engaged individuals are going to need things in simple, easy to read format that they can refer to multiple times.” A fifth content expert wrote, “Have quite a number of concerns in the implementation of a self-taught development, educational, and training program of this very broad concept. Transformation a leadership, is an extremely vast, varying methods, and evolving concept to be a self-taught educational package in the expectation of self-training/selfdevelopment and self-learning. (Especially when your audience varies from novice -to expert).” All the content experts discussed the need for examples of transformational leadership in the educational training program. Concern for first time learners not familiar with transformational leadership or those with limited to no experience and their ability to apply transformational leadership was raised. Inclusion of examples, possibly at each stage of Benner’s theory would

allow for increased clarity and understanding for learners at different stages.

Three of the content experts commented on the use of reflective practice in the educational training program. One content expert wrote, “I think the reflective approach is a good one to take, which will allow for charge nurses to learn from previous experiences they have had. I wonder if the last question might be more explicit and ask them what they learned from the experience and what they might do differently next time?”. A second content expert wrote, “I see that we are drawing from our own experiences to tie transformational leadership to our current practice, and while the key terms and theory are useful to understand I think there could be a bit more direction to the training program.” A third content expert wrote, “You might expand further on this instruction: “You will write down examples in the space provided that stand out to you in your leadership as a CN and answer the corresponding questions”.

Suggestions: Begin the instructions by asking the reader to reflect on various scenarios they have experienced as a CN and to provide an example of how TL was incorporated. You might also include what exactly will be required of the CN in the introduction. For example adding: ‘to promote understanding through reflective practice.’ Or something of the sort.” The comments of three out of five content experts supports the use of reflective practice in the delivery of the educational training program in conjunction with further instruction and direction relating to the educational training program and expectations of the learner of the training program.

Two of the content experts commented on the use of Benner’s theory in the educational training program. One content expert wrote, “The reason for choosing Benner’s Theoretical model versus others might be worth mentioning briefly so the learner understands why this particular models suites (sic) or achieves the learning objectives you are striving for.” A second content expert wrote, “Use of Benner’s theory as an expectation for all Nursing professionals is great as there is an expectation that all nurses are aware of this theoretical concept.-great!” The comments of two out of five content experts supports the use of Benner’s theory. It is worth considering providing rationale to the learner on selecting Benner’s theory for the educational training program.

Two of the content experts commented on the need to enhance leadership in nursing roles. Once content expert wrote, “Agree, there is a strong need to enhance leadership understanding/learnings, especially toward the CN’s in the ED depts of any hospital. As we know in the CN in an ED are the forefront for Staff and pt/families and equally the face of the Ed dept as a leader.” A second content expert wrote, “Certainly having people in informal (and formal) leadership roles who do not have an understanding of leadership styles is not ideal. Ideally all leaders undergo formal leadership style education. But this is not feasible. It can also be difficult to teach leaders about leadership styles without enrolling them in a formal course. This is related to amount of engagement and time required for each person to gain a true understanding of the topic.” The comments of two out of five content experts suggest the importance for enhancement of leadership in nursing roles. Consideration of staff engagement and feasibility as one content expert suggested is important when promoting understanding and the benefits of integrating transformational leadership strategies.

Implications for Future Nursing Practice

This project highlighted the need for consideration of enhancing leadership of informal nursing roles such as that of the charge nurse. Education and ongoing professional development through combination of didactic modalities, use of reflective practice and mentorship relationships are strategies to promote understanding and benefits of integrating transformational leadership strategies amongst charge nurses. This would require mobilization and support of senior and executive leaderships within an organization. Initial and ongoing investment in leadership education of informal leaders such as charge nurses is prudent to the sustainability of healthcare institutions and the healthcare system. Without investment into leadership education of charge nurses, health care organizations risk losing nursing staff. Studies by Al-Majid et al. (2018), Bognar et al. (2021), Dols et al. (2021), Sisk et al. (2021) and Teran and Webb (2016) found CN development within organizations positively impacted nursing retention rates. At a time, where a global pandemic has and continues to burnout large numbers of nurses, all solutions to enhance work environments must be considered. Bognar et al. (2021) reported positive workspaces led to job satisfaction among CNs and colleagues. To address long-standing issues within healthcare systems, organizations must prioritize leadership training of charge nurses within their organizations as they are the frontline leaders continually interacting with staff, patients, and families and have the potential to positively impact organizations and the healthcare system.

Future Recommendations

The purpose and intention of this project was to address a current gap in nursing and health related knowledge regarding the educational needs of charge nurses. Future projects and research should focus on exploring and examining barriers to implementing leadership training for charge nurses. Furthermore, future research and projects should focus on the cost/benefit analysis of leadership training for charge nurses. In addition, effects on patient outcomes, staff engagement, workplace culture are also areas of focus to be considered in future research and projects. Finally, Benner’s (1984) theory fit well as a theoretical framework to support the development of the educational training program and should be considered as a theoretical framework to support future projects and research related to patient care practice in this particular area of interest.

Summary

In summary, the purpose of this project was to promote understanding and the benefits of integrating transformational leadership strategies for charge nurses in a pediatric emergency room through use of an educational training program. 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 an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II presented a review of nursing and health related literature exploring the importance and benefits of integrating TL strategies for CNs in their role as frontline leaders. Chapter III discussed the intended project setting and population, a detailed description of the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary.

Chapter IV discussed the evaluation of the project; including a summary of content experts to strengthen the development of the educational training program, implications for future practice, and recommendations for future projects and research.

References

Al-Majid, S., Carlson, N., Kiyohara, M., Faith, M., & Rakovski, C. (2018). Assessing the degree of compassion satisfaction and compassion fatigue among critical care, oncology, and charge nurses.
JONA: The Journal of Nursing Administration, 48(6), 310-

Applicability—— Strongly Agree

Consistency ——-Agree.

Organization ——Strongly Agree

Evidence-Based Clinical Relevance — Strongly Agree

CONTENT EXPERT 2 (RN)

Clarity —– Strongly AgreeReadability ——Strongly Agree

Applicability—— Strongly Agree

Consistency ——- Strongly Agree

Organization ——Strongly Agree

Evidence-Based Clinical Relevance — Strongly Agree

CONTENT EXPERT 3 ( Nutritionist )

Clarity —– Strongly Agree

Readability ——Strongly Agree

Applicability—— Strongly Agree

Consistency ——-Agree.

Organization ——Strongly Agree

Evidence-Based Clinical Relevance — Strongly Agree

CONTENT EXPERT 4 ( Dietician )

Clarity —– Strongly Agree

Readability ——Strongly Agree

Applicability—— Strongly Agree

Consistency ——- Strongly Agree.

Organization ——Strongly Agree

Evidence-Based Clinical Relevance — Strongly Agree

CONTENT EXPERT 5 ( Dietician )

Clarity —– Strongly Agree

Readability ——Strongly Agree

Applicability—— Strongly Agree

Consistency ——-Strongly Agree

Organization —— Agree

Evidence-Based Clinical Relevance — Strongly Agree