Date of Award


Document Type

Restricted Access Thesis

Degree Name

Master of Arts in Nursing (MAN)



First Advisor

Joyce P. Miller DNP, RN

Second Advisor

Deborah Schuhmacher, DNP, RN

Third Advisor

Valerie Heintz, BSN, RN


Older adults admitted to skilled nursing facilities expect that their care will be well- managed during their stay. For many residents, the goal is to return home after a short-term stay. For others, the plan is to stay as a long-term patient with the assumption that medical needs will be met while in the facility. Regardless of the goal of care, hospital readmissions are costly and diminish the quality of life for these patients. Heart failure (HF) has been noted to be a top reason for rehospitalizations. A lack of knowledge of HF among licensed nurses within SNF settings has led to hospital readmissions. This project was created to establish an effective educational competency for licensed nurses after noting that 11 patients were rehospitalized between July and October 2020 at a 56-bed SNF within Southeastern Minnesota. At this SNF, there are no HF protocols established. A 17-slide PowerPoint presentation was developed to present applicable HF information to licensed nurses working in a SNF. In order to develop situational awareness among licensed nurses, a case study simulation was also created. A 20-point pre and post assessment tool was established to determine effectiveness of the competency. This project was guided by Jean Watson’s (2008) Theory of Human Caring with an emphasis placed on her Caritas Processes of transpersonal teaching and helping- learning. Concepts of transformational leadership and their applicability to advancing nursing practice were demonstrated in this project. Implications for future projects were also provided with the goal of inspiring other nurse to prevent hospital readmissions among older adults admitted to SNFs utilizing a variety of interventions.


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