Males in Nursing

Abstract

Nurse shortage is a considerable bother of the modern healthcare because it affects multiple stakeholders. The traditional methods of addressing nurse understaffing are designed using retention and hiring practices supported by empirical evidence. The present paper offers an innovative way of addressing understaffing by attracting more males to the profession. The proposed intervention is evaluated to increase the number of male nurses by 20% and improve the staffing situation by 15% in Eisenhower Health Center.

Even though there is little direct empirical support for the proposed method due innovativeness, critical appraisal of literature produced enough evidence to elaborate efficient male-specific hiring and retention practices. The project is expected to be implemented in Eisenhower Health Center due to its readiness to the proposed change. However, due to its cost-efficiency and relative simplicity, it can be easily replicated to improve staffing situation and gender diversity.

Introduction

Nurse understaffing is a considerable bother for the healthcare system in the US. According to Nei, Snyder, and Litwiller (2015), nursing was expected to experience the largest job offer growth of 26% among all professions by 2020. At the same time, nurse shortage is also expected to grow considerably (Haddad & Toney-Butler, 2019). The problem forces many scientists to look for the reasons for the matter and ways of addressing the issue.

For instance, Wei, Roberts, Strickler, and Corbett (2019) identify high turnover rates as one of the primary reasons for nurse understaffing and propose building positive interpersonal interaction and supportive organizational culture to improve nurse retention. The present project offers an alternative view on the problem and proposes addressing nurse understaffing by attracting more males to the profession.

Section A: Organizational Culture and Readiness Assessment

Knowing organizational culture (OC) is crucial for leaders since it can become a barrier or a facilitator of change. For the present evidence-based practice (EBP) project, a survey was conducted at Eisenhower Health (EH) among medical staff to understand if the organization was ready to embrace the proposed changes. Warrick (2017) suggests ten aspects of OC that a leader needs to know to effectively address the issues of a company. The survey offered by TalanLyft (n.d.) was adopted and modified to include Likert scale 12 questions providing thorough information about the ten aspects.

The results of the survey demonstrate that the culture of EH can facilitate the proposed change. According to the assessment, the strongest points of EH corporate culture are opportunities to learn new things, ability to generate new ideas and functional relationships among coworkers and supervisors. The primary reason for that is that the leaders of EH maintain the spirit of constant improvement and openly communicate matters with all the medical staff. According to Warrick (2017), the best way for leaders to strengthen weaker areas, such as clinical inquiry, is to role model the desired behavior. EH is filled with the spirit of clinical research since leaders of the organization always question traditional nursing practices and put them to the test.

The score of the survey was the lowest in the question concerning work-life balance. This matter may become a barrier to the proposed change since medical staff may be overloaded with current responsibilities. However, despite the possible obstacle, the assessment shows that EH is ready for the proposed change.

Section B: Problem Description

Background

The shortage of nurses is a critical problem of modern healthcare for various reasons. According to Haddad and Toney-Butler (2019), the demand for nurses is high and expected to grow since, by 2026, 1.1 million additional nurses will be needed to avoid a shortage. The reasons for the issue are numerous, including an aging population, an aging workforce, nurse burnout, and violence in the healthcare settings (Haddad & Toney-Butler, 2019).

Metcalf, Wang, and Habermann (2018) state the shortage of nurses is associated with an increased number of missed treatments. In other words, the problem of nurse understaffing may lead to a deterioration in the quality of care (Martin, 2015). Females traditionally dominate the nursing profession, and men in nursing are believed to be gay or hypersexual (Cottingham, Johnson, & Taylor, 2016). As stated by Cottingham, Dill, Choroszewicz, and Adams (2017), only 6.6% of nurses are males. The present project addresses the problem of understaffing among nurses by attracting more men to the profession and by altering traditional recruitment and retention strategies.

Stakeholders

The potential stakeholders of the proposed EBP project are numerous. First, the change is meant to improve the quality of care and patient outcomes; therefore, the central stakeholders of the proposed amendment are patients. Second, the nursing staff is expected to benefit from the project since nurse understaffing will be directly addressed, and sufficient nurse staffing is associated with increased job satisfaction (Haddad & Toney-Butler, 2019). In short, the project aims at benefiting two groups of stakeholders: nurses and patients of Eisenhower Health.

The change agents of the project are human resource (HR) staff since they are expected to promote the change. HR specialists will review and implement the men-oriented hiring and retention procedures proposed by the change. Additionally, managers will benefit from the project, as they will be provided with the additional workforce to complete their everyday tasks. The project will generate evidence that may be used by other hospitals; therefore, the list of potential stakeholders also includes all the nurses, leaders, and managers in the US. In short, the stakeholders of the EBP project are diverse and plentiful.

Purpose and Objectives

The use of the proposed change is to decrease nurse understaffing at Eisenhower Health by adopting male-oriented hiring and retention practices. The objectives to achieve the goal are as follows:

1. Increase the number of male nurses by 20% in 6 months;
2. Improve the staffing situation by 15% in 6 months.

The specific sub-objectives to complete the project are below:

1. Measure the understaffing rate among nurses and the percentage of male nurses at Eisenhower Health;
2. Review the available evidence concerning the shortage of nurses and male underrepresentation in the profession;
3. Assess the hiring and retention strategies of Eisenhower Health and elaborate a list of suggestions to improve HR practices;
4. Implement the proposed plan and evaluate the outcomes by assessing the changes in nurse staffing.

Supportive Rationale

The project proposes to use practices explicitly designed to attract male nurses. Yi and Keogh (2016) point out that the majority of male nurses if asked, would choose the profession again. However, the stereotype that men in nursing are gay or hypersexual prevents them from selecting the job (Cottingham, Johnson, & Taylor, 2016). Therefore, the HR department should utilize alternative recruiting strategies for male nurses (Kronsberg, Bouret, & Brett, 2018).

Specifically, Yu, Lou, Eng, Yang, and Lee (2018) state that HR specialists are to focus on career perspectives and elaborate a visual aid to depict a career path of a male nurse, focusing on time to highlight career steps and salaries. Additionally, since the underrepresentation of men in nursing is connected to social stereotypes, Stanley et al. (2016) recommend addressing the issue during recruitment. In short, the use of hiring practices elaborated for male nurses is expected to be successful since the intervention is supported by recent evidence.

Another way to address understaffing is by adopting effective retention strategies. These strategies can apply both to nurses in general and male nurses in particular. Rule, Bjornsdottir, Tskhay, and Ambady (2016) suggest fighting sexism in the workplace using posters and training sessions to reduce turnover. Wendsche, Hacker, and Wegge (2017) recommend improving the presence of regulated brakes to prevent nurse burnout. The evidence accumulated by the research mentioned above leads to understanding that a combination of these methods should improve retention rates among male nurses.

PICOT Question

In outpatient care settings (P), does focusing on male-oriented hiring practices, job satisfaction and retention (I), compared with traditional hiring practices, job satisfaction and retention (C), improve the situation with nurse understaffing and diversification (O) in six months (T)?

Section C: Literature Support

General Considerations

Critical appraisal of research is an integral part of an EBP project. Any change proposal should rely on results of valid, reliable, and applicable studies (Melnyk & Fineout-Overholt, 2019). The evidence should support both the problem and the proposed intervention to address the matter. While evaluating literature, a care provider is to state the strengths, limitations, and validity of every research (Smith & Noble, 2015). Below is a summary of evidence that supports the proposed intervention to address the issue of understaffing of nurses in outpatient care.

Search Method

The search for evidence to support the problem and intervention was conducted between the beginning of April and the end of July 2019. Grand Canyon University library, Cochrane Database, Medline, and Google Scholar were used to acquire the needed information. To be included in the review, articles were supposed to be written in English, published not earlier than 2014, and address the topic of the shortage of nurses or the unequal gender representation of men in the profession. The keywords were “nurse understaffing,” “men in nursing,” “nurse retention,” “male hiring nursing.” The search generated many results; however, only 30 of them were included in the initial reference list.

Problem

Glette, Aase, and Wiig (2017) conducted a literature review and thematic analysis of thirty-three studies which showed that the insufficient number of nurses might be associated with increased patient harm and mortality (Glette et al., 2017). The strengths of the study include the number of considered articles and the methods used for information extraction and literature review. However, the results are limited since the review concerns only nurses, and the articles are written solely in English. The validity of the methods is confirmed by various studies, as mentioned by the authors.

Kiekkas et al. (2019) also explored the problem of nurse understaffing in their observational, single-center, prospective study. After studying 2,207 patients admitted to the post-anesthesia care for five months, Kiekkas et al. (2019) concluded that insufficient nurse staffing is associated with a higher incidence of hypoxemia and arterial hypotension. The strength of the research is the sample size while the study is limited to only one facility and 5-month period. Cross-validation and verification of collected data were ensured to prevent bias.

Metcalf, Wang, and Habermann (2018) surveyed hospital managers and reviewed its results to study correlations between the number of missed treatments and staffing of front-line employees. The validity of the survey was assured by pre-test and revision. The strength of the research is the number of hospitals under study, while the apparent limitation is the use of subjective data. In short, the three studies mentioned provide sufficient evidence to confirm that nurse understaffing is a critical issue in modern reality.

Intervention

The proposed intervention to address the problem of insufficient staffing is attracting more men to the profession by focusing on career opportunities while hiring and anti-sexism posters and training sessions. Clow, Ricciardelli, and Bartfay (2015) surveyed 165 undergraduate students to confirm that the focus on masculinity while hiring male nurses may be associated with role incongruity. The primary strength of the study is the reliability since the method for analyzing data was appropriately used. However, even though the study had a robust conceptual framework, validity remains a limitation.

Carrigan and Brooks (2016) conducted a literature review of 31 articles to understand the reason for the insufficient number of males in the nursing profession. The strength of the articles is the holistic approach to the matter, while the significant limitation of the research is the absence of clearly articulated methods. The article may be classified as expertise, and the validity cannot be assessed.

Rule, Bjornsdottir, Tskhay, and Ambady (2016) conducted multiple studies of different experimental and non-experimental designs that confirm that male nurses are considered to be gay, which leads to sexism in the workplace. The strongest points of the research are its reliability and validity of external and internal. However, the samples are only US citizens, which limits the study to one country.

Yi and Keogh (2016) reviewed four papers out of 11,458 search results to understand why males fail to choose nursing as a profession. The obvious limitation is the number of sources and their qualitative nature. However, the apparent strength of the study is that six reviewers assessed the research. Therefore, the validity of the study is high, and the results are trustworthy.

Stanley et al. (2016) employed a non-experimental, comparative, descriptive research design focused on a quantitative methodology to understand why men choose nursing as their profession. The 34-item questionnaire was distributed online among 1055 respondents, which is a relatively large sample size. The survey is characterized by strong content validity and high Cronbach’s Alpha of 0.91 (Stanley et al., 2016). However, the research results are limited only to Western Australia.

Twomey and Meadus (2016) recruited 239 male nurses to conduct a qualitative study to understand the reasons for choosing the profession and barriers of becoming a nurse. The instrument used for assessment scored high in content validity, while Cronbach’s Alpha was 0.71 (Twomey & Meadus, 2016). While the significant strength of the research is its validity and the sample size, its results are limited only to Atlantic Canada.

O’Connor (2015) conducted a qualitative study interviewing 18 male nurses about their reasons for becoming a nurse. While the research provided valuable results, the small sample size limits the study’s generalization capabilities. However, since the research method is reported to have been tested by authoritative scholars, the content validity of the method and its reliability is high.

Section D: Solution Description

Proposed Solution

The proposed solution to understaffing of nursing is designing and implementing male-oriented hiring practices, job satisfaction, and retention. In particular, hiring advertisements should picture more men in the nursing profession (Carrigan & Brooks, 2016). However, these advertisements should avoid emphasizing the masculinity of men to avoid the perception of role incongruity (Clow, et al. 2015). During the interview, the focus will be on the career perspectives by presenting nursing as a stable, “flexible and reasonably well-paid job, where specialization and further education is possible” (Yi & Keogh, 2016, p. 103).

As for retention practices, male role models will be established by honoring more men as valuable employees, as recommended by Twomey and Meadus (2016). In addition, all policies will be revised to make the wording more gender-neutral, and anti-discrimination rules will be emphasized as proposed by Carrigan and Brooks (2016). Since the proposed solution is supported by substantial evidence, it is expected to be successful.

The intervention is also projected to provide positive outcomes since it is realistic and cost-efficient. The costs of the implementation of the intervention are associated only with the revision of the current documentation and additional training for human resource (HR) managers. Since no special equipment or supplies are required, the expenses will be minimal. Therefore, the intervention is realistic, and no changes are needed to start the process.

Organization Culture

The offered intervention is consistent with the organization culture of Eisenhower Health (EH). The readiness assessment conducted using a survey by TalanLyft (n.d.) revealed that the culture of EH could facilitate the proposed change. According to the evaluation, the strongest points of EH corporate culture are opportunities to learn new things, ability to generate new ideas and functional relationships among coworkers and supervisors. Additionally, workplace culture welcomes gender and racial diversity due to its perceived positive effects. In short, the culture of constant change and tolerance is expected to facilitate the implementation of the proposed solution.

Expected Outcomes

The anticipated outcome of the project is expected to improve the situation with nurse understaffing and diversification. In particular, it is expected to increase the number of male nurses by 20% and decrease nurse shortage by 15%. Since staffing is closely associated with patient outcomes, the intervention can indirectly reduce patient morbidity and mortality (Metcalf, Wang, & Habermann, 2018). Additionally, adequate staffing should improve job satisfaction among medical personnel of EH. In short, the intervention is perceived to bring positive changes to medical practice and administrative processes.

Method to Achieve Outcomes

The project is designed to utilize Roger’s Diffusion of Innovation theory that proposes to divide the intervention into four steps (Lien & Jiang, 2017). The steps are described in Section E of the present proposal and follow the advice provided by Deeken et al. (2017). The specific barriers that need to be assessed and eliminated are listed below:

• The availability of enough HR managers to participate in the project;
• Support from upper-management to allocate sufficient resources for the initiative;
• Lack of knowledge and skills to revise hiring and retention policies.

From the current stand, there are no identified limitations or assumptions, which may need to be addressed.

Outcome Impact

The outcomes are expected to make a considerable impact on the patient-centered quality of care and the workplace environment. Improved front line care provider staffing is associated with a decreased number of missed treatments (Metcalf et al., 2018). Additionally, Glette et al. (2017) mention that the lack of nurses may be associated with decreased patient safety. The matter is also confirmed by Kiekkas et al. (2019) since the research found positive associations between hypoxemia and arterial hypotension and post-anesthesia care unit understaffing.

Therefore, an improved situation with nurse understaffing will improve the quality of patient-centered care by providing timely and appropriate procedures. Speaking about the workplace environment, EH is expected to become a more diverse organization that will attract more males and racial minorities due to improved tolerance and reduced prejudice.

Section E: Change Model

The Importance of Theoretical Framework

When implementing practice changes, it is crucial to incorporate theories or models for various reasons. First, a relevant model is beneficial for planning future change by identifying the critical stages to achieve success (Batras, Duff, & Smith, 2016). Second, a theoretical framework helps to evaluate the outcomes of the undertaking. Ultimately, the utilization of an appropriate theory saves time and resources (Wilson et al., 2015). The existing evidence-based project was initially designed to adhere to Lewin’s change theory; however, after further consideration, it was decided to use Rogers’ diffusion of innovation (DOI) theory to approach the PICOT question (Lien & Jiang, 2017). The present paper carries implementation through each of the stages identified in the chosen model.

Change Model Overview

DOI is one of the oldest social science theories and is still being used extensively by various organizations. DOI aims at understanding how a change can be effectively disseminated or diffused. In 1962, E. M. Rogers identified five types of people, depending on their readiness to adopt change (Lien & Jiang, 2017). The order of categories to accept innovation are innovators (2.5%), early adaptors (13.5%), early majority (34%), late majority (34%), and laggards (Lien & Jiang, 2017).

According to DOI, there are four crucial steps to effective adoption of new practices: awareness, decision to adopt or reject, initial use, and continuous use (Lien & Jiang, 2017). The conceptual model presented in Figure 1 is similar to Lewin’s change theory with a valuable addition of deciding whether the proposed project needs to be implemented. DOI has been proving its effectiveness for the last fifty years. For instance, the utilization of the theory reduced the prevalence of tobacco smoking in Australia, from 40% to 15.9% in less than thirty years (Lien & Jiang, 2017). In short, DOI is expected to be beneficial for planning the change of the existing project.

Describing Major Steps

Awareness

Similar to the unfreezing stage of Lewin’s change model, the first step is arousing dissatisfaction with the current situation by spreading awareness about the problem. According to Haddad and Toney-Butler (2019), the demand for nurses is high and expected to grow since, by 2026, 1.1 million additional nurses will be needed to avoid a shortage. One of the ways to address the matter may be by attracting more males to nursing.

One of the reasons for the lack of men in the profession is inadequate recruitment practice (Carrigan & Brooks, 2016). The awareness stage implies that HR managers are to be informed about the problems with the current hiring and retention strategies. For this matter, current practices will be reviewed, and suggestions to improve them will be made. After that, an information letter with the critical appraisal table will be sent to the HR department to suggest a change. In the letter, a particular emphasis will be put on expected outcomes.

Making the decision

The HR department will review the letter, and a formal meeting will be organized to discuss the suggestions. During the meeting, representatives of all the stakeholders will be invited to evaluate if the proposed project is worth implementing. The decision to adopt will be made in the course of open voting if all the participants of the meeting agree with the suggestions.

Initial use

Roger’s third step is similar to the moving stage proposed by Lewin’s moving stage, during which a pilot project is launched. During this phase, all the HR managers will be using the new hiring and retention strategies to address the problem of nurse understaffing. After six months of initial use, the practice will be evaluated by experts, and the decision about further use will be made. Additionally, corrections will be made to improve the method using internal evidence.

Continuous Use

If the new practice is found beneficial, further utilization of the strategies will be suggested. The final step of DOI coincides with Lewin’s refreezing stage. The remaining changes to the project will be made to ensure that the prolonged use of the practice will be beneficial for all stakeholders. After six months of initial application, the innovation is expected to become a standard strategy for hiring and retention of nurses.

Section F: Implementation Plan

Settings

The project will be implemented in the human resource (HR) department at Eisenhower Health (EH). The HR department will enforce the new nurse hiring and retention policies on the hospital grounds. The potential subjects are all EH nurses, in particular new nurses. Informed consent is unnecessary since the project is not dangerous nor beneficial for the subjects.

Time Needed

The project will consist of seven objectives and require seven months to implement. Below is the list of all tasks with estimated completion times. The timeline for the project may be viewed in Figure 1 in the appendix for the present paper.

• Review of current practices and understaffing and retention rates (1 week);
• Elaboration of the list of suggestions (1 week);
• Assessment of the recommendations by the HR department (1 week);
• Making the decision (1 day);
• Implementation of changes (6 months);
• Review of the results (1 week);
• Deciding if alterations are needed or if the practice be discontinued (1 day).

Resources

The proposed project is cost-efficient since it does not require any special equipment, innovate clinical tools, or extensive training. Moreover, the intervention does not need additional human resources or considerable financial investments. During the implementation, the process of hiring will be revised and changed. The resource list is presented below.

1. Project manager;
2. HR managers;
3. Standard office equipment, including computers, printers, and paper.

The Process of Delivering the Solution

The delivery will be concentrated on two matters: the implementation of new hiring procedures and application of the revised set of retention practices. For the first part, new job advertisements picturing male nurses will be elaborated and distributed using traditional channels. These advertisements will be reworked to focus more on stability and career opportunities. Moreover, HR managers will be describing career opportunities to male applicants and provide printed nursing career path examples with an average yearly salary. According to Carrigan and Brooks (2016), these practices are expected to attract more males to the nursing profession.

For the second part, upper management will be encouraged to create role models by describing successful life stories of male nurses and posting them on social media and the official hospital information portal. In addition, one of the hospital awards will be renamed in honor of the male healthcare professional. Hospital policies will also be revised to emphasize zero tolerance of workplace sexism. According to Villarruel, Washington, Lecher, and Carver (2015), the procedures described above are expected to improve the retention of male nurses.

Management Strategies

Close analysis revealed no potential barriers, facilitators, or challenges. However, to ensure that the goals of the programs are fully achieved, emphasis will be placed on training and cross-training of staff members; so staffing issues will not adversely affect the program. The training process, however, will be relatively brief since the intervention is not complicated.

Feasibility

Since the project does not require an extensive amount of resources, its financial burden is relatively low. No additional personnel, equipment, or computer-related costs are expected since the resources of the facility are sufficient to implement the project; however, there are some matters that will require minor investments. First, EH will be expected to pay for three one-hour training sessions for the HR managers to embrace new hiring and retention practices. Second, the facility will need to pay for the design and distribution of new advertisements. Third, the revision of current policies may also be associated with additional printing costs.

Finally, EH will pay for the publication of job advertisements. However, since the hospital would publish them anyway, the matter is not considered to be an additional cost. Table 1 in the appendix for offers a budget plan for the current project.

Methods, Data Collection, Plans

The existing project does not require any specific instruments to measure success. Understaffing and retention rates will be measured before and after the implementation. Per protocol for the department, the data will be collected and stored by the HR managers. Then, numbers will be compared, and qualitative expertise will be performed to understand the reasons for success or failure. The analysis will be performed during the meeting after six months of initial use of the proposed strategies. Last, participants of the conference will decide if the project should be maintained, extended, modified, or discontinued.

Section G: Evaluation of Process

Rational for Methods

The primary method of measuring the success of the project is by comparing the understaffing and retention rates among nurses before and after the intervention. A simple comparison of the numbers will provide clinically significant information about the effectiveness of the proposed method. However, it will provide no information concerning the reasons for the results. Therefore, an expert committee will evaluate the logic behind the numbers to provide a supporting rationale for the acquired results.

The methods mentioned above are proposed for several reasons. First, the approaches are relevant to the PICOT question since they assess if male-oriented hiring and retention practices positively affect the situation with nurse understaffing. Second, the methods are easily comprehendible, and there expected to be no complications with the interpretation of results. Even though the opinions concerning the reasons for success or failure may differ among the experts, there should be no complications while using them. Third, the proposed intervention is cost-efficient since the final cost is estimated to be $4000. Since the matter requires little financial investments, it is more likely to be embraced by the upper management of any healthcare facility.

Measuring Outcomes

The supposition of the understaffing and retention rates among nurses before and after the intervention will provide exact information if the objectives are achieved. The objectives are to increase the number of male nurses by 20% and to improve the staffing situation by 15%. If the difference between the measurements is 15% and 20% respectively, the objective will be considered achieved. The expertise will be particularly helpful if the results are unsatisfactory since it will provide reasons for the failure. The benefits of the approaches are high reliability and applicability to the research question.

Even though the method is adequate, it has some evident flaws that need to be stated. The results may be not valid due to the small sample size and insufficient time to test the hypothesis. Additionally, the results will be limited to one healthcare facility and will be insufficient to generalize the implications. In short, the validity of the method may be low due to objective reasons; however, the approach remains valid.

Negative Results

While the acquisition of positive results is a desirable outcome, negative results are also a valuable addition to the body of evidence concerning nurse understaffing. If the intervention proposed by the present project fails to produce positive outcomes, the results will be disseminated. According to Kratochwill, Levin, and Horner (2017), negative results are underreported in the scientific literature. The matter may be associated with failure to adequately evaluate an intervention before implementation.

For instance, the literature review for the present paper revealed that there is little knowledge about exact strategies that can help to attract more males to the nursing profession. In this case, information about unsuccessful interventions would help to avert the mistakes that have already been made by other researchers. Therefore, the first thing to be considered if the project produces negative results is disseminating the findings to help other healthcare professionals avert similar mistakes.

The intervention will be revised and modified to increase the possibility of positive outcomes. Since the final expertise is expected to provide abundant information concerning the flaws of the intervention, there will be enough data to process and create a more viable intervention to improve the situation with nurse understaffing. Moreover, an additional literature review will be conducted to find recent research concerning men in the nursing profession. In brief, the second strategy will be to improve the intervention incorporating the suggestions of the expert committee and recently published literature.

Conclusion, Implication for Practice, and Future Research

In case of positive results, the project will have significant implications for the nursing practice. According to Martsolf et al. (2016), adequate nurse staffing level positively influences patients’ experience during the hospital stay. Therefore, an intervention that helps to address the problem of shortage of nurses is expected to improve the overall quality of care. As for future research, the intervention can be easily replicated to address the problem of low validity. If the effectiveness of the solution is confirmed in other healthcare facilities, the generalizability of the conclusions will be improved. Cost-efficiency and simplicity of methods are expected to promote the replication of the study.

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Appendices

Appendix A: Rapid Critical Appraisal Checklist for Systematic Reviews

Appendix B: Rapid Critical Appraisal Checklist for Qualitative Studies

Appendix C: Literature Evaluation Table

Appendix D. Conceptual Model

Appendix E: Proposed Timeline

Appendix F: Budget Plan