Abstract
The World Health Organization (WHO), 2010 noted that recent research has identified several psychosocial and biologic risk factors for postpartum depression (PPD). Early recognition is one of the major challenges with this overwhelming mood disorder. The main focus of this project is to provide easy access to educational materials to aid in the screening, assessment, and treatment of women who experience depression during pregnancy or the postpartum period. PPD was amended by The American Psychiatric Association, in the 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), to peripartum depression and specifies that the onset of mood disturbance can occur in pregnancy or within four weeks of childbirth. The obstetrician and pediatrician can serve important roles in screening for and treating this under-recognized and undertreated illness. There is a need for the for implementation ofing a wide spread screening for postpartum women because early detection may be a challenge for women with postpartum depression.
Postpartum depression (PPD) is a mood disorder that is historically neglected and underdiagnosed in health care, leaving mothers to suffer in fear, confusion, and silence. Women with PPD sometimes do not disclose their feelings or their symptoms due to shame fear or embarrassment (Beck, 2002). Mothers should receive attention from their outpatient therapists for the first year after child delivery especially those who report that they feel overwhelmed and anxious since childbirth. Undiagnosed PPD can adversely affect the mother–infant relationship, and lead to long-term emotional problems (Dennis, 2010) for the child. Early detection of PPD is vital in order to improve maternal and newborn health. If a new mother has risk factors for depression before discharge from the hospital, plans can be made for frequent follow-up, perhaps by telephone, and specific interventions can be implemented.
PPD exhibits (Beck, 2010), all the typical symptoms of depression such as low mood, anxiety, crying, irritability, insomnia, and mood lability, but is distinguished by its manifestation after the childbirth. Although the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (2004) states d that the depressive episode begins within four weeks of birth, many clinicians and researchers (Dennis, 2010) agree that this description is too limiting,.limiting, and. It is postulated postulated that postpartum depression can occur up to a year after childbirth. .
The World Health Organization (WHO) 2010 statedd that depression is greatest in women; with a lifetime risk of 20% to 25% for major depressive disorder, approximately twice the 7% to 12 % rate with men. In 2010, WHO explained that in the first three months after childbirth, 14.5% women have new onset of major depression and 10% to 20% of mothers are believed to suffer with depression sometime during their postpartum course. Without treatment, postpartum depression can last for months or years. In addition to affecting the mother’s health, it can hinder her ability to bond with connect with and care for her baby, and may cause the baby to have problems with sleeping, eating, and behavior as he or she grows. The purpose of this paper is to improve the early detection of PPD through the education of clinicians about the screening and assessment of post-partum women for the presence of PPD by using solid evidence-based practices, and to empower women who suffer from this oft-undiagnosed illness.
For women who suffer from PPD, an assessment of need for interventions is a treatment goal. Thus, screening and diagnostic tools such as the Postpartum Depression Predictors Inventory-Revised (PDPI-R) are of paramount importance in obtaining not only a diagnosis, but also serve as a powerful assessment of need that helps identify women who are at-risk of developing PPD. Such tools are an invaluable resource for clinicians, and pregnant or postpartum women. Moreover, when properly educated about PPD, clinicians can assess the needs of their female patients with greater accuracy, thereby improving the quality and timeliness of interventions with regards to any subsequent treatment.
Literature review.
Beck’s (date2002) program of study on PPD represents a substantial contribution to nursing practice. This theory has focuses oned a heightened awareness of PPD through the development of a midrange theory, and promotes the assessment and treatment of PPD (Lasiuk & Ferguson, 2005). Midrange theory is is said to be more concrete and situation-specific (Lasiuk & Ferguson, 2005). Beck’s theory ((date)2002), and research program clearly embracembraceses a complete approach to accepting the experience of PPD that is consistent with the viewpoint and ideals of nursing.
WHO ((date2010) presented a synthesis n meta-analysis of qualitative studies of postpartum depression that found that women’s experiences of motherhood differed from their expectations quite markedly. This Postpartum Depression (PPD) Literature Review of Risk Factors and Interventions Interventions is a comprehensive review of the literature in four related areas: 1) risk factors for postpartumPPD risk factors depression, 2) its detection, prevention and treatment of PPD, 3) the effects of the illness on the mother- infant relationship and child growth and development and 4) public health interventions and strategies which to reduce or mitigate the impacteffect of postpartum depressionPPD on the mother-infant relationshipbonding and the growth and development of children (WHO, 2010).
According to Lasiuk & Ferguson,, (2005),, Beck’s theoretical underpinningsy of PPD have become more widely-accepted, and becomes apparent in this successful work and in the development of the Postpartum Depression Predictors Inventory-Revised (PDPI-R) is now referred to as, “a tool to identify women at risk for developing PPD” (Lasiuk & Ferguson, 2005, p. 134). In addition, tThe PDPI-R “is a checklist of risk factors determined through two meta-analyses to relate to PPD” (Lasiuk & Ferguson, 2005, p. 134). The PDPI-R is not a self-report tool. It must be used as a clinician-structured interview. The guided questions assist will help clinicians into concludinge whether a specific risk factor is present or not. The authors explained that the first 10 predictors of the tool can be assessed during pregnancy and the postpartum period. The Then Tthe last three3 risk factors are assessed after a mother has delivered. Once the PDPI-R is completed, it identifies targeted risk factors for which nursing interventions can be planned to address each mother's problems.
Quality and Safety Education for Nurses.
Evidence--based practice, as defined by The Quality and Safety Education for Nurses (QSEN), is the integration of best current evidence with clinical expertise and patient/family preferences, and values for delivery of optimal health care (Grdina, 2014). Evidence--based interventions s are important in improvingto improve both maternal and infant health outcomes associated with pregnancy (Lasiuk & Ferguson, 2005). Education regarding PPD should begin before or during pregnancy. This is an effective will be a good way to of educatingeeducate nurses who are not familiar with the postpartum depression.
Process Selection
The main focus of this project is to provide easy access to educational materials for the women with postpartum depression to educational materials to aid in the screening, assessment, and treatment of women who experience depression during pregnancy or the postpartum period. Goldmann (2011), stated that projects should be selected to make a major difference to the patients and healthcare providers who will participate in them. Early detection of PPD is vital in improving maternal and newborn health. A description of the revised postpartum depression predictors inventory is attached in the Appendix. This process change is necessary due to numerous patients whothat are affected by postpartum depression. The Postpartum Depression Predictors Inventory-Revised (PDPI-R) was developed from the findings of two meta-analyses on postpartum depression risk factors (Beck, 2002). PPDI-R (Beck, 2002) is described as an inventory in the form of a checklist that consists of eight risk factors found in the meta-analyses to be significantly related to postpartum depression. After a woman delivers her baby, using the PDPI-R will provide a continuous monitor of the woman’s risk status because she can develop postpartum depression at any time during the first year (Beck, 2002). One of the advantages of the PDPI-R is that it can be used during both prenatal and postpartum periods to identify women who are at risk for postpartum depression. Furthermore, the Edinburgh Postpartum Depression Scale (EPDS) is an effective tool that detects PPD, and aids clinicians in basic decision-making in screening for major depression in patients already diagnosed with PPD (Please see APPENDIX for a flowchart of the EPDS). The process change is safe, efficient and effective. It is also patient-centered. This tool was selected because postpartum women are frequently admitted to inpatient psychiatric units, but have little insight about the symptoms that comprise a PPD diagnosis – let alone the definition of PPD. with no clue to what the problem is.
Collaboration to Redesign
For an effective change to take place, there must has to be a collaborative effort between of the clinicians, the nurses, and the physicians, as well as and healthcare staff in other different departments. The stakeholders of this process redesign are in this case will be: the patient, who is at the center of the care team, and; the providers whichthat which includes the physician, nurse practitioner, and physician’s assistant who is (as a coordinated triad) are responsible for leading the team. Other stakeholders include; medical assistant(s) who are responsible for preparing the visit, checking-in and rooming patients, ensuring that post-visit tasks are completed, and ensuring that patients understand the follow-up plan. Additional stakeholder includeincludes Also, nurses, social workers, and or health educators who provide self-management support, arrange other resources, and provide care coordination or other services.
Change would begin at the regular office preantenatal visits. The pediatric nurse and the nurse practitioner would be responsible for the PPD screening process, while the physician would both interpret the results of the screening process, and design a treatment plan based upon the results. The patient will be better screened if the process starts earlier sooner than later in pregnancy. Maternal depression significantly interferes with parenting cognitions and behaviors and places the child at increased risk for cognitive and behavioral problems. These negative effects begin in the early infant environment such that interventions to treat depression in mothers with very young children are of the highest priority. Collaborative care (Dennis, 2010), is an approach to treatment that is highly effective for the management of depression in primary care settings. Case identification occurs at the primary care level in a collaborative care model with a depression care manager directing individuals to appropriate treatment and monitoring progress. This is done in collaboration with a mental health specialist (Dennis, 2010).
Process Redesign
Process redesign entails the incorporation of the PDPI-Revised into continuous healing relationships between pre-partum, pregnant, peripartum, and postpartum women – and their healthcare providers. Thus, everyone serves as an integral part on the team, which requires the feedback and compassion of all stakeholders. On the part of the patient, if such an early screening, detection, treatment, and monitoring process is to work, a high degree of trust in her team is necessary. Moreover, she must be allowed, and encouraged by her healthcare team to be honest and forthcoming about her emotions and cognitions.
Continuous healing relationships.
. The availability of the PPD screening tool for the immediate use of assessing depression during antenatal visits establishes a key link of the the relationship between patient and the clinician or nurse. Moreover, sStrong patient-provider relationships foster improved communication, trust, and knowledge of patient context and preference (Institute of Medicine, 2001). Not only does a strong patient-provider relationship lead to improved patient satisfaction, but it has also been consistently linked with improved health behaviors, and better health outcomes (Dennis, 2010). It is imperative that the screening tools are available not only in the offices, but also on the internet. Access to care and clinician- or nurse–patient relationship can also be provided by telephone in addition to face-to-face at the provider’s office. A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel of patients. Who is on the care team and their specific roles will vary based on patient needs, and practice organization.
Impact of Process Change.
It is anticipated that, in conjunction with solid evidence-based practices, the widespread usage of the PDPI-Revised for early detection of PPD will become more common. Thus, the women who suffer from undetected and untreated PPD will certainly decline over the long term. Moreover, the implementation of the PDPI-Revised will ensure that antepartum, preipartum, pregnant, and postpartum women are adequately screened for PPD by their healthcare team. Such an implementation will result in adequate treatment modalities for those women who went previously undiagnosed for the illness.
According to McGrath et al. (2007), the PDPI-Revised has immense, albeit untested, value in PPD screening. The researchers state that, “More information about the sleep problems experienced, perhaps gained through interview using the PDPI-R as the guide, may result in critical information useful for research and practice” (McGrath et al., 2007, para. 12). Furthermore, McGrath et al. (2007) note that, since the PDPI-Revised has somewhat recently incorporated new scoring methods, it has become a more valid and reliable tool for the early assessment and screening of PPD.
Thus, there is a great deal of hope, and studies point in a positive direction toward a more thorough screening of PPD by the usage of solid evidence-based practices, a compassionate, multi-disciplinary team, and a solid, reliable screening tool such as the PDPI-Revised. While only a scant number of studies address the impact of this design – perhaps due to its difficulty to identify and quantify its many variables – the impact of process change can be expected to be markedly significant.
Additional Process Redesign Criteria
Finally, criteria for process redesign must be considered. That is, the clinical evidence of PPD, as a whole, must be broken down into its sum-parts in order to evaluate its methods and results. In terms of its implications for health policy, role of nurse leader, management of change and conflict, role of evidence-based delivery, use of information technology, as well as ethical principles and theories, meeting the unique requirements for each category is vital.
Implications for Health Policy.
The extensive utilization of both clinically-sound evidence-based practices (EBP), as well as the selection of an accurate and reliable prognosticative tool such as the PDPI-Revised will have profound implications for health policy. As controversial as they are, sound application of EBP can be applied to mental health care (Tanenbaum, 2005). Moreover, Tanenbaum (2005) states that the so-called predominant medical model makes the therapeutic intervention more effective, thereby improving overall well-being. Thus, effective treatment modalities can transform healthcare policy with respect to the treatment of PPD, alleviating the most severe signs and symptoms of mental illness.
Role of Nurse Leader.
The nurse leader plays a significant role in the entire process of health care delivery for women diagnosed with PPD. For example, their responsibilities will include monitoring their female patients at regular visits. However, some patients may require additional monitoring, depending on the degree of their PPD, Moreover, they will play an integral role in both the assessment and screening of patients by utilizing the PDPI-Revised tool in order to assist them in making accurate diagnoses. After thorough assessment and screening for PPD, as well as the appropriate use of current evidence-based practices, the nurse leader will document all aspects of the patient’s physical, cognitive, and emotional signs and symptoms. Subsequently, the nurse leader will transition all of the patient’s health information to the physician, who will then interpret the patient’s records, and possibly diagnose the patient for PPD. After the physician’s diagnosis, and the nurse leader’s referral to mental health specialists – preferably with experience in the treatment of PPD – the patient will continue to be evaluated by the nurse leader.
According to Monaghan (2011), the role of a clinical nurse leader (CNL) has changed dramatically over the past several years, and they have learned to take on the responsibility seeing patients at the point of care. Thus, nurse leaders, such as CNLs, have taken on new challenges, such as the transfer of knowledge, and so-called “interdisciplinary relationships” (Monaghan, 2011, para. 9). This new role strengthens the CNL as a nurse leader in the vital, and delicate dynamic of patient and health care providers.
Management of Change and Conflict.
Change and conflict are inevitable circumstances in any workplace, let alone the clinical setting of any healthcare facilities. According to Ramsay (2001), conflict can be, at the least, defused and outbursts can be de-escalated through immediate an immediate address of the issues, and adequate conflict management education, which includes an explanation of intervention measures in order to “prevent further disruptive behavior, [a list of] ways to prevent conflict and [even] violence in the workplace, [as well as] the [explanation] of the importance of emotional intelligence” (Ramsay, 2001, para. 1). In addition, Ramsay (2001) suggests that a capable leader must employ both tact and diplomacy as part of conflict management and resolution, skills that are absolutely essential in any clinical or hospital setting. One can presume that such skills may be especially invaluable when interacting with women who may be depressed and/or anxious.
Change is a constant, regardless of the setting. Certainly, change is an ongoing aspect of healthcare, given its ever-transforming system of access and delivery. Nonetheless, there are time-tested ways to both manage, adapt, and succeed in an environment where daily changes are inevitable. Al-Abri (2007) recommends that all healthcare stakeholders have a clear vision of how to operate within the parameters of change in the dynamic context of the healthcare setting.
Furthermore, Al-Abri adds that healthcare must be customized to a community population’s needs in order for healthcare delivery to be effective (Al-Abri, 2007, para. 10). Finally, clear channels of communication and effective programs that promote overall awareness must be established as protocol in order to manage the always-increasing speed of change in the healthcare profession (Al-Abri, 2007, para. 10). Specific to the assessment, screening, diagnosis, and treatment of PPD, key stakeholders must stay abreast of change, and adapt accordingly.
Role of Evidence-Based Delivery.
There are several criteria that effectively underscore the of evidence-based delivery in the early detection of PPD. For example, identifiable risk factors, such as antenatal anxiety, antenatal depression, existing life stressors, a history of depression, self-value, supportive social networks, and spousal supportiveness are key evidence-based guidelines for assessment of risk in women who potentially have PPD (Joseph, 2014). Thus, the early detection of PPD is the primary criteria for early detection and treatment of an illness that is much more common than previously thought, both in the US and globally (Joseph, 2014).
In addition, Palumbo & VanMeter (2011) stress the importance of both public awareness and education with regard to the risk factors that contribute to the incidence of PPD. Thus, evidence-based delivery is more effective in light of high public awareness and adequate education (VanMeter, 2012, p. 2). Seemingly, such education could extend to public school health courses, and community outreach efforts – such as free clinics, colleges and universities, churches, homeless and/or domestic violence shelters, bus stops, and other public venues.
Use of Information Technology.
The use of information technology is an exciting new avenue for the early detection of PPD. Information technology is growing exponentially, and shows no signs of slowing down. For patients, the potentials are virtually limitless, as mobile phone applications are now becoming more commonplace, as Jiménez-Serrano et al. (2015) have noted.
Not only have Jiménez-Serrano et al. (2015) developed models that classify and detect risks for PPD during the first week postpartum, but they have even created a mobile health, or m-health app, for Android® platforms. Such apps help mothers monitor a multitude of factors with regard to their postpartum status, but also assist physicians in collecting accurate data by using software noted for its high predictive reliability, and easy user interface (Jimenez-Serrano et al., 2015, para. 1).
Ethical Principles and Theories.
Certainly, ethical principles and theories must guide and inform every step of additional process redesign criteria. Without a moral compass, healthcare would lack all of its required ingredients: compassion, cooperation, respect for patient rights, teamwork, and integrity. Thus, the role that ethical principles and theories play in the early detection of PPD differs little from other applications of such principles and theoretical guidelines.
Green & Bloch (2001) point out a number of ethical challenges that the current mental healthcare system fails to overcome. Mothers who are diagnosed with PPD may find themselves enduring such unresolved systemic challenges. According to Green & Bloch (2001), the primary ethical challenges facing the mental healthcare system are daunting. For example, Green & Bloch state, “curtailed inpatient treatment may allow resources to be distributed among the many but also greatly diminish the well-being of a minority of people suffering from severe forms of mental illness” (Green & Bloch, 2001, p. 1379).
Thus, it stands to reason that women with severe cases of PPD could become marginalized by a system that fails to treat – much less address – their more serious mental health needs. Thus, patient dignity suffers from a system that focuses almost exclusively on the majority of PPD sufferers, at the expense of the more serious sufferers of the illness (Green & Bloch, 2001). Fidelity, as defined by Bloch & Green (2001), is negatively affected in this regard. Moreover, another aspect of fidelity that is negatively affected is the preferential treatment of clientele by psychiatrists, who may find themselves in the midst of a conflict of interests with respect to financial and patient concerns (Green & Bloch, 2001). In such cases, psychiatrists are more likely to order expensive tests for clientele who do not need them (Green & Bloch, 2001).
Although there are considerable ethical challenges that the mental health care system must resolve, i.e. illnesses such as PPD that the current system fails to take seriously. Thus, attempts to address the mental healthcare system’s deficits and injustices could result in increased public awareness of the urgent necessity for the early detection of PPD. In light of considerable challenges to ethical principles and theories, the incidence and seriousness of PPD could attract a spotlight to a dysfunctional mental health care system that is in dire need of repair. Lastly, the early detection of PPD could ultimately become a national (and global) priority, one that finally improves the early detection and prognosis of PPD sufferers
Conclusion
This author concludes that, the use of the PDPI-R and early awareness of PPD and with the implementation of evidence-based care has the potential to improve outcome for mothers with postpartum depression, their infants, and families. This is through early identification of depressive symptoms with referral and treatment that is sensitive to individual mothers’ needs.
References
Al-Abri, R. (2007). Managing change in health care. Oman Medical Journal, 22(3), 9–10. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294155/
American Psychiatric Association (2000)..: Diagnostic and sStatistical mManual of mMental dDisorders 4th ed. (DSM-IV) (4th ed.) .). Washington, DC: American Psychiatric c Association., 2000.
Beck, C. T. (2002). Revision of the Postpartum Depression Predictors Inventory. Journal of Obstetric, Gynecologic & Neonatal Nursing, 31(4), 394-402. Retrieved March 18, 2016, from
http://www.jognn.org/article/S0884-2175(15)33990-3/pdf
Dennis, C. (2010). Mothering Transitions Research. Evaluating Collaborative Care for
Postpartum Depression in Early Childhood Primary Care Settings.
Goldmann, D. (2011). Ten tTips for incorporation scientific quality improvement into everyday work. BMJ Quality Safety, 12, 69-72.
Grdina, R. (2014, October 8). QStudent #4: Evidence bbBased ppPractice | QSEN. Retrieved March 19, 2016, from
http://qsen.org/evidence-based-practice/
Green, S.A., & Bloch, S. (Sep, 2001). Working in a flawed health care system: an ethical challenge. American Journal of Psychiatry, 158, 1378-1383. Retrieved from https://www.researchgate.net/profile/Sidney_Bloch/publication/11813007_Working_in_a_Flawed_Mental_Health_Care_System_An_Ethical_Challenge/links/562793cd08aecd3ce8d1ba22.pdfInstitute
Jiménez-Serrano, S., Tortajada, S., & Gárcia-Gómez, S.M. (Jul, 2015). A mobile health application to predict postpartum depression based on machine learning. Telemedicine Journal and E Health, 21(7); 567-74. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25734829
Joseph, B.R. (26 Sep, 2014). Early detection of postpartum depression: evidence based risk assessment guidelines. Sigma Theta Tau International Leadership Connection. Retrieved from https://stti.confex.com/stti/leadfm14/webprogram/Paper68083.html
Lasiuk, G. C., & Ferguson, L. M. (2005). From practice to midrange theory and back again;
Beck’s theory of postpartum depression. Advances in Nursing Science,
28(2), 127-136.
McGrath, J. M., Records, K., & Rice, M. (2008). Maternal Depression and Infant Temperament Characteristics. Infant Behavior & Development, 31(1), 71–80. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294155/http://doi.org/10.1016/j.infbeh.2007.07.001
Monaghan, H.M. (Apr, 2011). Clarifying the clinical nurse leader role: guardian of care. American Nurse Today, 6(4). Retrieved from https://americannursetoday.com/clarifying-the-clinical-nurse-leader-role-guardian-of-care/
Palumbo, A., & VanMeter, A. (Nov, 2012). Prevention of postpartum depression related to mode of birth delivery. Pharmacy and Nursing Student Research and Evidence-Based Medicine Poster Session. Cedarville University. Retrieved from http://digitalcommons.cedarville.edu/cgi/viewcontent.cgi?article=1037&context=pharmacy_nursing_poster_session
Ramsay, M. A. E. (2001). Conflict in the health care workplace. Proceedings (Baylor University. Medical Center), 14(2), 138–139. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291328/
World Health Organization. (2010). Mental health and development: Targeting people with
mental health conditions as a vulnerable group. WHO Press Geneva, Switzerland.
4/1/16 Fola, this is an important project. I spent several hours reading and completing feedback for you related to this paper. I sincerely hope that my feedback is accepted in the spirit that it is given – to learn and improve.
Much of your paper is unclear and some sections did not meet the grading criteria set forth under “Content” of our D2L course (see also the grading rubric posted under “Content” of our D2L course). A logical flow and organization of the content are lacking. There was a template posted under “Content” for this paper, however, you did not follow the template.
I gave you credit for one quality management tool (the screening tool) in the “Assessment of Need” section although you did not reference the tool in this section rather under “Process Selection”. This tool appears to be your redesign although you did not make reference to it in the “Process Redesign” section. What is expected in the “Assessment of Need” section in addition to a literature review and use of one QSEN competency, is a quality management tool from our course. Consider whether a flowchart of the initial process (prior to use of the screening tool) might be used to clarify where in the process the screening needs to take place. Alternately you might use a run or control chart to display patients who were seen in the clinic, not diagnosed with PPD and were later admitted for inpatient psychiatric care. The tool is at your discretion, but if you need assist, please contact me.
Next, in the “Process Redesign” section you did not include (as required) a reference from scholarly literature to support process redesign. Nevertheless, you did cite references to support your redesign in other section, thus I gave you credit for that criteria. Again, this demonstrates a lack of organization of your paper. You did not include the use of a quality management tool (perhaps a revised flowchart after the screening tool was in place) nor did you reference an applicable QSEN competency as required (-2 points).
You completely omitted the final required section, “Impact of Process Change”. This is one of the most important parts of your paper because it demonstrates the outcome of your work. This section was (-6) points, thus a significant portion of your grade for this paper. This quality management tool could be a run or control chart documenting screenings that were completed (or positive whichever is most important to measure) or additional data (from the tool that I discussed above) noting perhaps a decrease in the number of patients admitted to an inpatient psychiatric facility.
Finally, you must seek assistance with your writing style and application of APA format. I provided a template under “Content” for this paper. I am unsure why it was not used? Please review the need to improve your writing with your advisor. I also strongly recommend that you contact the East Tennessee State University (ETSU) “Center for Academic Achievement (CAA)” formally called “The Writing Center” as soon as possible to secure assistance with your writing. Please specify that you also need assistance with APA format. The link to the CAA is HYPERLINK "http://www.etsu.edu/uged/cfaa/" http://www.etsu.edu/uged/cfaa/ . Because it is near the end of the semester, the center workers are very busy, so your request must be done as soon as possible. The assistance is available in person and online. Please let me know if your work with those individuals was helpful. Also, I am willing to assist you in any way possible, please let me know how I may assist you.
You have a lot of work to do on this paper (see my comments above and let me know if you have questions or concerns). Make the requested changes to this paper and submit it as the first part of the final paper for this course.
I want to assist you. You are at risk to not pass the course unless you score almost maximum points for the remainder of the assignments in the course. Please contact your advisor and discuss this with her as well so that she is aware. Please let me know how I can assist you by email or mobile at (423)-794-8074. Sincerely, Dr. Diffenderfer
Quality Management Project Paper
Grading Rubric 25%
Appendix
