Date of Award

Fall 12-3-2021

Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Mary Brann, DNP, RN

Second Advisor

Karen Gilbert, DNP, MS, RN, CDP


Practice Problem: Individuals with Alzheimer's disease and related dementias cannot verbalize their care needs during transitions of care (TOC) and rely on their home caregivers (HCs) for advocacy. The lack of communication between clinicians in one setting and HCs can lead to detrimental health outcomes for the length of stay.

PICOT: The PICOT question that guided this project was: With the assistance of family nurse consultants (P), how does the implementation of standardized care needs communication tool for support persons of persons with dementia (I) vs. no standardized process (C) enhance the ability for the support person to communicate care needs during TOC (O) within 5 weeks (T)?

Evidence: The review of high-quality studies reveals evidence that supports clinician-home caregiver communication as an approach to bridge gaps for the person with dementia (PWD) across health care settings. Intervention: The clinician-home caregiver communication checklist was used as an evidence-based tool to enhance the HC’s ability to communicate care needs for the PWD during care transitions.

Outcome: There was a clinically significant improvement with the family nurse consultants’ utilization of the tool, and HCs who were offered the tool benefited from that time of preparation for their loved ones. There was a statistically significant improvement in family nurse consultants’ perception of the value and usefulness of the tool after they were introduced to it.

Conclusion: The project findings revealed that using the standardized care needs communication tool, HCs can be crucial members to strengthen TOC for the cognitively impaired individual.


Scholarly project submitted to the University of St. Augustine for Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

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This work is licensed under a Creative Commons Attribution 4.0 License.