The Daughter-in-Law Learns the Pen Too: A Patient and Family Engagement Program for Bhutanese Nepali Adults Going Home on New Insulin
Student Name
American College of Education
NUR5063: Patient-Centered Care
Module 4 Assignment
Instructor Name
February 2, 2027
The Transition and Why It Fails
Patients from the composite diabetes center described in earlier modules are admitted to the hospital's medical units for problems such as severe hyperglycemia, infections of the foot and heart failure. A review of the past year's records found 38 admissions of Bhutanese Nepali adults during which insulin was started or its regimen changed. Of those patients, 11 returned to the emergency department within 30 days, seven for low or high blood sugar, and only 15 were seen at the diabetes center within two weeks of discharge.
Chart review and interviews with staff and families showed why. Insulin teaching was done by the day nurse with the patient alone, often through a telephone interpreter, while the family member who would give the insulin at home was at work. Discharge instructions were printed in English. Follow-up was booked by letter. The Module 2 assessment found that in this community, adult children and daughters-in-law usually manage medicines and appointments, and that help-seeking begins within the family. The hospital was teaching the person who would not give the insulin, in a language the household could not read, and then writing to a house where no one opened English mail.
The Engagement Framework
Carman et al. (2013) describe patient and family engagement along two dimensions. The first is a continuum running from consultation, in which patients receive information and are asked for their views, through involvement, to partnership and shared leadership, in which patients and families share power and responsibility. The second is the level at which engagement happens: direct care, organizational design and governance, and policy making. The framework is useful here because it shows that the hospital's current practice sits at the consultation end of the continuum and only at the level of direct care, and that a program limited to better handouts would stay there.
The program aims to reach involvement and partnership at the level of direct care, where families will share the work of learning and deciding, and involvement at the level of organizational design, where patients and families from the community will shape the program itself.
Program Components at the Bedside
Identifying the family partner. On admission, the nurse asks the patient, through a trained interpreter, who helps with medicines and appointments at home and whether that person should be part of the care plan. The answer is recorded in a family partner field in the record, and the patient's choice is respected if the patient prefers not to involve family.
A family teaching session. When insulin is started, the nurse schedules a teaching session at a time the family partner can attend, including evenings, with an in-person or video interpreter. Both the patient and the family partner practice with the pen, demonstrate a glucose check and explain back the plan for low blood sugar, using the picture-based materials and recorded Nepali audio developed in Module 3. Discharge does not proceed until at least one person in the household has demonstrated the injection correctly.
A community health worker across the transition. A Nepali-speaking community health worker from the community meets the patient and family before discharge, helps them set one or two goals for the first weeks at home, visits the home within 72 hours and stays in contact for at least four weeks. The model follows the randomized trial by Kangovi et al. (2014), in which community health workers built action plans with low-income inpatients around the patients' own recovery goals; patients in the intervention group were more likely to see a primary care clinician within 14 days, reported better discharge communication and were less likely to have repeated readmissions. Yun et al. (2016) found that Bhutanese refugees readily sought out community navigators and preferred helpers who could model how to deal with the health system, which suggests the role fits this community particularly well.
Coaching the family to speak up. The Care Transitions Intervention trained a coach to help adults aged 65 and older and their caregivers take charge of their own transition, and its patients were readmitted less often at 30 and 90 days than those in usual care (Coleman et al., 2006). Borrowing that idea, the community health worker will help the family keep a simple record of readings and medicines, recognize warning signs and prepare two questions for the follow-up visit, which the center will schedule by telephone in Nepali before discharge.
Engagement in Program Design and Governance
The program will be overseen by a working group that includes two Bhutanese Nepali patients or family members, recruited through the community association and paid for their time, alongside the nurse manager, a diabetes educator, the community health worker and a hospital interpreter. The working group will review the teaching materials each quarter, hear from families whose transitions went badly and decide on changes. The hospital's patient and family advisory council, which has no member from this community, will also be asked to add one. These steps reach involvement at the organizational level; true shared leadership would mean families helping to set the program's budget and priorities, and the working group will be asked after the first year whether that is wanted.
Anticipated Barriers
Three barriers are likely. First, evening teaching sessions compete with the day's workload on units that are already short of staff at shift change, so the program will start on one unit and add the second only when the first unit's nurses report that sessions are running without delaying other care. Second, some patients will not want a family member involved, or will name a grandchild who is too young to carry the responsibility; the nurse will respect the first choice and, in the second case, ask whether an adult can share the role, with the community health worker helping to find one. Third, a single community health worker is a fragile resource. If that worker is ill or leaves, the home visits stop. The working group will therefore train a second community member as a part-time backup during the first six months, and the program will keep a short written guide so that the role does not live only in one person's memory.
Roles, Resources and First Measures
The program needs one full-time community health worker, funded for the first year from the hospital's community benefit budget, and protected time for nurses on the two medical units to teach in the evening. The diabetes educator will train unit nurses in family teaching and teach-back, and the interpreter service will add evening video coverage in Nepali. The nurse manager of the medical units is accountable for the program, and the community health worker reports to the diabetes center's nurse manager so that the role belongs to the setting patients return to.
Early measures will include the percentage of eligible patients with a family partner recorded, the percentage of households with a demonstrated injection before discharge, diabetes center visits within 14 days and emergency visits within 30 days. Module 5 will add measures of how patients and families experience the transition in their own words and scores.
References
Carman, K. L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (2013). Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Affairs, 32(2), 223-231. https://doi.org/10.1377/hlthaff.2012.1133
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822
Kangovi, S., Mitra, N., Grande, D., White, M. L., McCollum, S., Sellman, J., Shannon, R. P., & Long, J. A. (2014). Patient-centered community health worker intervention to improve posthospital outcomes: A randomized clinical trial. JAMA Internal Medicine, 174(4), 535-543. https://doi.org/10.1001/jamainternmed.2013.14327
Yun, K., Paul, P., Subedi, P., Kuikel, L., Nguyen, G. T., & Barg, F. K. (2016). Help-seeking behavior and health care navigation by Bhutanese refugees. Journal of Community Health, 41(3), 526-534. https://doi.org/10.1007/s10900-015-0126-x
How this NUR 5063 Module 4 example is structured
NUR 5063 Module 4 in many sections designs a patient and family engagement program, often around a care transition; your classroom's instructions decide the transition and whether a budget or timeline is required. This example defines the transition and its risks, chooses an engagement framework, designs the program at the levels of direct care and organizational design, grounds each component in evidence, and sets out roles, staffing and the first measures.
NUR5063 Module 4 questions, answered
What does NUR5063 Module 4 usually ask for?
NUR5063 Module 4 in many sections asks you to design a patient and family engagement program, often built around a care transition such as hospital discharge. Many sections expect a named engagement framework and evidence for each component. Your classroom's instructions decide the details.
Which engagement framework should I use?
Any framework your course materials name. The Carman framework is widely used because it separates how deeply patients are engaged, from consultation to partnership, from the level where engagement happens, from bedside care to governance and policy.
Does the program need patients in its governance?
A strong program usually includes them. Show how patients or family members will help design or review the program, how they will be recruited and supported, and be honest about how much decision-making power they will hold.
Write yours, or have the desk draft it
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