NURS 500 Week 3 Research Proposal Part 1, Background, Significance and Research Questions Example

Caregiver Teach-Back Before Discharge and Tube-Related Emergency Visits After a New Gastrostomy, Part 1: Background, Significance, and Research Questions

Each year, a few hundred adults in the service area of a regional hospital in Southwest Virginia go home with a feeding tube that did not exist when they were admitted. Most have had a stroke, a head and neck cancer or a progressive neurologic disease that made swallowing unsafe, and most depend on a spouse, adult child or friend to give feedings, flush the tube, give medications through it and care for the skin around it. A review of the hospital's discharge records for 2025 found that 27 of 112 adults discharged home with a new percutaneous gastrostomy returned to an emergency department within 30 days for a problem with the tube itself, most often a blocked tube, leakage at the site or a tube that had come out. Nearly every one of those visits began with a caregiver at home deciding, often at night, that a problem was beyond what they had been taught to handle. This proposal describes a study to test whether a different way of teaching caregivers before discharge changes that number.

Background

Home enteral tube feeding allows people who cannot swallow safely to be nourished outside the hospital, but it shifts complex daily care to family members. Amaratunga et al. (2023) described patients receiving home enteral feeding as being at high risk of complications and readmission, and their systematic review of service improvements found that targeted education for patients, carers and staff improved knowledge right after teaching and that the gain held at three to six months. Multimodal programs reduced complications such as infection, blockage and displacement, yet none of the reviewed interventions reduced unplanned hospital encounters, and the authors rated the evidence low in quality.

The burden on caregivers is substantial. In a multicenter cross-sectional study of 90 caregivers of patients on home enteral nutrition, Folwarski et al. (2024) found that 57% had depression and 19% rated their quality of life as poor, and depression was correlated with caregiver burden, poor sleep and stress. A caregiver who is exhausted and uncertain is more likely to treat a partly blocked tube or a red stoma as an emergency. In a qualitative study of 15 caregivers of patients with a new gastrostomy, Santos et al. (2024) described caregivers who felt confused and unsure early in hospital teaching and who reached a sense of mastery only after hands-on practice with feedback from nurses; even then, complications such as tube obstruction and accidental tube loss occurred at home, but trained caregivers were able to manage them.

The way caregivers are taught may matter as much as what they are taught. Discharge teaching on many units consists of a demonstration, a printed handout and a question such as "Do you have any questions?" Teach-back replaces that question with a request that the learner explain or demonstrate the skill in their own words, and the nurse then corrects and re-teaches until the explanation is accurate. In a systematic review of 20 studies, Talevski et al. (2020) found teach-back effective in 19, with benefits ranging from knowledge recall to self-care and some health service outcomes, although most studies were of moderate or weak quality and few were conducted with caregivers.

Significance to Nursing

Discharge teaching is an independent nursing function, so a better method of teaching is a change nurses can make without new equipment or orders. The problem also has costs that reach beyond the patient. An emergency visit for a dislodged tube in a rural county can mean a long drive, hours of waiting and sometimes a replacement procedure; for an older adult who has had a stroke, that trip carries its own risks of aspiration, missed feedings and missed medications. For caregivers, each unplanned visit reinforces the sense that they cannot manage, which the Folwarski et al. (2024) findings suggest feeds the cycle of stress and depression.

The study also matters for the profession's evidence base. The review by Amaratunga et al. (2023) found no intervention that reduced unplanned hospital encounters and called for higher-quality research, and the teach-back studies reviewed by Talevski et al. (2020) rarely measured whether better caregiver understanding kept patients out of the emergency department. A rigorous test of nurse-delivered teach-back for gastrostomy caregivers would address both gaps. From a Christian worldview, the study also reflects the call to care for those who carry burdens for others; equipping a caregiver well is a practical way of honoring the work they have taken on.

Theoretical Framework

Orem's self-care deficit theory provides the framework (Orem, 2001). Orem described the dependent-care agent as the person who meets the self-care needs of someone who cannot meet them alone, and nursing's role as helping that person develop the knowledge and skill to do so through supportive and educative nursing systems. A caregiver managing a gastrostomy at home is a dependent-care agent, and discharge teaching is the educative nursing system. Within this framework, teach-back is a method for confirming that dependent-care agency has actually developed before discharge, and a tube-related emergency visit is one observable sign of a dependent-care deficit.

Purpose and Research Questions

The purpose of this quasi-experimental study is to examine whether structured teach-back education with return demonstration, delivered by trained nurses to family caregivers before discharge, reduces tube-related emergency department visits within 30 days among adults discharged home with a new percutaneous gastrostomy, compared with usual discharge education. The study will answer three questions:

• 1. Among adults discharged home with a new gastrostomy tube, is the proportion with a tube-related emergency department visit within 30 days lower when the family caregiver receives structured teach-back education than when the caregiver receives usual discharge education?
• 2. Do family caregivers who receive structured teach-back education report higher caregiving preparedness on the day of discharge than caregivers who receive usual education?
• 3. Among all caregivers in the study, is preparedness at discharge associated with a tube-related emergency department visit within 30 days?

Two directional hypotheses follow. The first hypothesis is that the proportion of patients with a tube-related emergency visit within 30 days will be lower in the teach-back group than in the usual education group. The second hypothesis is that mean preparedness scores at discharge will be higher in the teach-back group. The third question is exploratory and carries no directional hypothesis.

Definitions of Variables

The independent variable is the type of caregiver education. Conceptually, structured teach-back is an educative nursing system in which the caregiver explains and demonstrates each skill and the nurse corrects until performance is accurate; operationally, it is a protocol of at least two sessions covering six skills (feeding, flushing, medication administration, site care, recognizing complications and responding to a dislodged tube), each completed only after an accurate return demonstration documented on a checklist. Usual education is the unit's current demonstration and printed handout.

The primary dependent variable is a tube-related emergency department visit, defined conceptually as unplanned emergency care for a problem with the gastrostomy tube or stoma and operationally as any emergency visit within 30 days of discharge whose chief complaint or diagnosis involves tube dislodgement, occlusion, leakage, site infection or site pain, identified from the health record and a day-30 telephone call. Caregiver preparedness, the second dependent variable, is conceptually the caregiver's perceived readiness for the tasks and demands of caregiving and is operationally the mean score on the eight-item Preparedness for Caregiving Scale developed by Archbold et al. (1990), completed on the day of discharge.

References

Amaratunga, H., Bostock, K., Cunich, M., Steffens, D., & Carey, S. (2023). Systematic review of service improvements for home enteral tube feeding in adults. Nutrition in Clinical Practice, 38(2), 329-339. https://doi.org/10.1002/ncp.10900

Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. (1990). Mutuality and preparedness as predictors of caregiver role strain. Research in Nursing & Health, 13(6), 375-384. https://doi.org/10.1002/nur.4770130605

Folwarski, M., Maciejewska-Cebulak, M., Skonieczna-Żydecka, K., Sumlet, M., Kupiec, M., Jankowska, B., Kwella, B., Balul, G., Szafrański, W., & Kłęk, S. (2024). Quality of life of caregivers of patients on home enteral nutrition. Clinical Nutrition, 43(9), 1983-1990. https://doi.org/10.1016/j.clnu.2024.07.011

Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). Mosby.

Santos, J. M. D., Pedreira, L. C., Góes, R. P., Souza, M. A. A., Baixinho, C. R. S. L., Ortega, J., De La Rosa, R. N., Sousa, A. R., Silva, V. A. D., Pinto, I. S., Santos, J. L. P., Vivas, L. C., & Oliveira, L. M. S. (2024). Caregivers' mastery in handling gastrostomy at home after educational intervention: Qualitative descriptive study. Healthcare, 12(21), Article 2147. https://doi.org/10.3390/healthcare12212147

Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4), Article e0231350. https://doi.org/10.1371/journal.pone.0231350