NURS FPX 6085 Assessment 2 Problem Statement (PICOT)

NURS FPX 6085 Assessment 2 Problem Statement (PICOT) 

Student Name

Capella University: Department of Nursing

NURS-FPX6085: MSN Practicum and Capstone

Professor Name

Submission Date

Problem Statement (PICOT)

However, this is a serious matter that is currently impacting the most populated cities in America, namely, access to healthcare is insufficient. One of the main reasons for this is that there are problems with people not knowing the medical jargon or medical terms used by medical care providers. This leaves a communication void and leads to a communication gap between providers and patients. Coupled with an inability to utilize available services, adults who are poor and do not have health insurance have limited access to healthcare. Indeed, as Campbell noted, implicit bias and lack of communication between providers and patients are both important factors involved in the struggle of racial and ethnic minorities to access health care. These inequities in health care for these populations can be addressed only by equipping all nursing staff with standardized training that will help them communicate with patients.

PICOT

In an urban acute care health care environment, can a structured motivational interviewing (MI) training program, when compared to regular communication without MI training, decrease the barriers to care for low-income uninsured adults over a 12-week implementation period among all RN providing direct care to low-income, uninsured adults?

Problem Statement

Need Statement

But there are numerous obstacles to the health care system for low-income urban residents and families who are not insured. These obstacles can lead to poor patient satisfaction, poor adherence, and poor quality of care. Common problems are inadequate communication between patient and provider, cultural incompetence of the provider, and the provider’s implicit bias against the patient. When combined, they can decrease patients’ engagement and present additional challenges in the health care system. Challenges with patient/provider communication and provider time to engage with patients are barriers to quality health care for populations that are traditionally underserved, according to Schwarz. Nursing education programs to enhance communication skills and to prepare nurses to meet these barriers are immensely needed.

Population and Setting

Registered nurses (RNs) in urban acute-care environments are the target population for this intervention, as they regularly care for low-income, uninsured adult patients who have restricted access to health care services. There are significant numbers of people who are not adequately represented in urban acute care settings, which provides a rich opportunity to help mitigate inequities in accessing healthcare services. According to Campbell, health care providers often reinforce health disparities in urban acute care settings as a result of unconscious bias and ineffective communication practices. Thus, in the acute care environment, particularly in urban areas, RNs will be in direct contact with vulnerable people.

Intervention Overview

One structured 12-week program of MI training will include weekly one-hour sessions with an MI-certified trainer and role-plays, bi-weekly feedback on performance, and continued support through the program to focus on core MI skills: open-ended questions, reflective listening, affirmation, and collaborative goal setting. For low-income uninsured adults who are vulnerable to negative health outcomes and use acute care services in urban areas, the intervention will be executed by engaging a physician, a social worker, a case manager, and an RN in interprofessional strategies of communication and collaboration to provide coordinated, patient-centered care. This team collaborative approach will provide a framework for effective communication, shared decision-making, and consistency in the application of the MI process across disciplines and within this population. The findings of the Boom study demonstrated that HCP who received MI training were more confident in applying MI in their interactions with patients and developing therapeutic alliances, and Cole stressed that to make a real difference in clinical outcome, there needed to be intentional, supervised skill training by the entire care team.

Comparison of Approaches

At present, there are no formal systems to incorporate motivational interviewing and patient-centered communication into the interaction of current nursing practice. Because the traditional nursing communication model lacks specific training on effective communication with the underserved population, nurses are lacking in the means to communicate effectively with these populations other than through routine posts to teach patients and to give them discharge instructions. According to Cole’s study, the use of motivational interviewing has proven to provide better outcomes than the traditional approach, increasing the patients’ intrinsic motivation and decreasing their resistance to accessing care and engaging in the process. A comparison between nurses who were trained to use motivational interviewing versus nurses who use standard approaches will enable us to determine if barriers to care are reduced by the intervention.

Initial Outcome Draft

This project should have an impact on the measurable competency and care engagement of patients in nursing. Specific outcome measures include greater satisfaction with nurse communication by patients, fewer missed appointments, and higher scores on the motivational interviewing (MI) competency scores of nurses. There is some evidence that MI interventions yield moderate to large effects on patient self-confidence and disease- management behaviors, across a variety of patient populations (as suggested by Ghizzardi). These outcomes will be combined to contribute to the overall objective of reducing provider-level barriers that may be experienced by low-income, uninsured adults accessing health care services.

Evaluation Criteria

Outcome information will be obtained through systematic and objective methodologies, with the measures to be developed before implementation. Patient satisfaction will be assessed using a valid measure (a Communication satisfaction survey, baseline and week 12). A standard instrument (MITI coding system) will be used to evaluate the nurse’s competence in motivational interviewing (MI) and to include fidelity measures for specific techniques of MI. The implementation of MI through a systematic approach should entail the use of structured assessment tools, which help identify areas where MI is weak or not implemented, as well as to guide future improvements to the clinical practice of MI. The main outcome indicators for assessment of outcomes will be: At the end of the period of intervention, a statistically significant improvement will be deemed when the number of students who satisfy a minimum of 2 of the 3 core outcome indicators is statistically significant.

Time Estimate

Emergence and implementation of the proposed intervention are distinct and have a clear time frame of 12 weeks. The first 2 weeks will be for baseline data collection and introduction to the program for participant nurses. Based on Laroche’s 12 months of MI and coaches’ experience, a 12-week intense version is suggested as an introductory approach that makes significant differences. The final outcome measures will be achieved after 12 weeks and will be reviewed after 6 weeks for any concerns regarding the program implementation.

Quality Improvement Method

This project is based on a quality improvement framework that involves using the Plan-Do-Study-Act (PDSA) cycle to measure and refine nurse communication practices in an acute care, urban environment. Baseline nurse communication practice (and patient engagement) data will be gathered during the planning process to determine performance gaps. The do phase will consist of providing nurses working with low-income uninsured adults with the 12-week structured motivational interviewing (MI) training program. Structured MI interventions that were implemented over time, as shown in a study by Bilgin (1998), resulted in significant improvements in patient self-efficacy, emotional state, and clinical results. During the act phase, to evaluate nurse MI competency and patient engagement outcomes, pre- and post-intervention data will be compared. The findings of the act phase will be used during the Refining/Sustaining Phase to further develop and sustain the training program with improvements incorporated into continued practice.

Literature Review

The literature already shows that there are barriers to health care services for adults without insurance living in urban areas who have low incomes. These barriers include: Lack of communication with the provider, the time given on consultations, and a low level of health literacy. In addition, Campbell’s study adds to this understanding by stating that implicit bias among healthcare providers plays a direct role in how providers misdiagnose patients, under-treat them, and create a lack of trust towards underserved individuals. Ghizzardi conducted a systematic review and meta-analysis, which showed moderate to large effects of MI on self-care confidence and disease management in patients with HF. Bilgin found that a meta-analysis showed that MI significantly lowered HbA1C levels, lowered depressive symptomology and emotional distress, and raised self-efficacy levels among patients with diabetes. In their study, Laroche had shown that MI was practicable and acceptable among families with low incomes, and that there were important behavioral changes towards health in this population when MI was added to the community resource support. The odds of successful weight loss and overall health among adult Hispanics who receive interventions incorporating MI delivered by CHWs will be significantly higher than among those receiving standard care, the Brown research concluded.

To effectively implement MI within clinical settings, attention must be paid to: 1) structured training; 2) continued support; and 3) barriers from clinical settings. Each of the four primary components of MI (engaging, focusing, evoking, planning) demands intentional skill development and practice in a supervised environment and with feedback to attain clinical proficiency. In a study of over 14,000 exchanges of counselling by CLM’s, reflection and affirmation skills in the context of MI were identified as the top correlate of client satisfaction in peer counselling contexts. In addition, a systematic review and validation were done by Self et al. (2023) to demonstrate that culturally adapted MI significantly improved outcomes compared to controls in racial/ethnic minorities and that the effects were larger than those in the general population, thus emphasizing the need to tailor MI training for a diverse population of people served by nurses. Participants in the underserved and Latino communities were satisfied with the interventions and felt that implementing MI-based interventions across a range of community settings was feasible.

In the literature, motivational interviewing (MI) has been found to be effective and suitable in various clinical settings for the nursing intervention proposed. A systematic review Orciari et al) confirmed small but reliable effects of MI on the behaviours of substance misuse among homeless persons; however, the study emphasized the need for structural support to facilitate the use of MI as a stand-alone intervention. The results of the systematic review done by Pinto e Silva indicated that motivational interviewing techniques have the potential to greatly aid increased patient adherence to treatment, decrease dropout rates, and increase motivation to change for many intervention programs. Motivational interviewing is a scalable tool that can be used in the clinic, but also provides more access for clients who are not able to consume it in person due to transportation or time constraints, according to Abid and Baxter’s research. 

Evaluation of Relevance and Currency

Literature shows that the urgency or need for alternative intervention methods for nurses who care for underserved individuals, such as motivational interviewing, has been demonstrated. Studies cited in this paper are from the period of 2021-2025, as all literature reviewed falls within this time frame, and so the studies cited represent the current knowledge on the use of MI and barriers to healthcare access. The level of adaptation for cultural differences and the continued positive results with various racial/ethnic groups have also been validated via self-research, providing further evidence of the effectiveness of MI as an intervention in urban settings in which patients live who are a mix of cultures. The results of the studies reviewed indicate that nurses are able to provide training on MI to their patients.

Health Policy

Health policy has an impact on how nurses engage and advocate for patients in their professional roles who are marginalised. The Future of Nursing: 2020-2030 report calls for nurses to contribute to the social determinants of health by eliminating health disparities across the country. According to Campbell’s study, health care professionals are ethically accountable for their own part in ensuring inequities in health care delivery systems through implicit bias and poor communication. Creating cultural competency and effective communication policies for nurses will directly improve the goal of access to care for low-income, uninsured adults.

Health Policy, Technology, and Practice Considerations

Nurses now have more ways to use technology and telehealth solutions in delivering patient-centered communication, outside of regular clinical settings. According to Abid and Baxter, utilizing AI-based motivational interviewing (MI) technology enables scalable and more widely accessible ways of increasing patient adherence and engagement with their behaviors in the health care setting. This is where policy needs to play a role to help promote the use of evidence-based communication training, like MI, in nursing school curricula, as well as continuous nursing education.

Identified Needs and Missing Information

The existing studies on motivational interviewing (MI) in the nursing field suggest that MI can be effective and reveal some weaknesses in the literature regarding the impact of MI on nursing practice in the urban acute care setting, where patients lack any health insurance, as well as where most of the patients’ income is insufficient to cover their expenses. Most MI research has taken place with physicians and community health workers, and with outpatients. Hence, the research reporting the impact of MI on nursing practice in acute care is scant. In addition, very little data exists to support the effectiveness of MI with a very low-income population, and therefore, particular attention should be given to conducting research with this population to support MI effectiveness.

Conclusion

The research problem statement and literature review have given an evidence-based problem, identifying the need for the implementation of a structured motivational interviewing training program in acute care nursing in cities. There is an urgent need to provide training to urban acute care nurses to help eliminate barriers to successful treatment that many low-income, uninsured adult patients experience due to barriers within the communication process. Without action from health care providers to tackle their own unrecognized forms of bias, and ultimately their own relationship with patients, the systemic inequities are sustained in our health care system as a whole.