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High- and Low-Quality Transitional Nursing

Literature Review

The quality of transitional care is analyzed in many research articles. A study by Toles, Colón-Emeric, Asafu-Adjei, Moreton, and Hanson (2016a) explores the strategies of transitional nursing for the elderly in skilled nursing facilities (SNFs). In this case, the authors compare the results of transitional care and usual care and evaluate different interventions that can improve patients’ outcomes, including their readmission rates and quality of life. According to the study, one’s transition from an SNF to home can be followed by the deterioration of health, which is explained by the patients’ age and limited social support. Therefore, proper transitional care can significantly improve one’s well-being. Toles et al. (2016a) outline a number of commonly utilized interventions for transitional care, including discharge planning and patient education prior to discharge, and visits to patients after discharge.

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This article is also interesting because it presents some ideas for successful implementation of high-quality transitional care. For instance, the researchers note that these procedures should be performed with the help of additional Registered Nurses (RNs) and social workers, who can help patients have a smooth transition. Furthermore, they argue that nurses who provide transitional care should have specialized training. Care planning is also highlighted as a necessary activity that can benefit many patients. Geriatricians should be added to the team to accommodate older patients. The study proposes to use various tools for providing care, including electronic health records and “screening and assessment templates” (Toles et al., 2016a, p. 299). The scholars conclude that patient outcomes in transitional care are often inadequate. The main problems connected with their transition in need of improvements, and transitional care should be viewed as a way to prevent patients from having postdischarge complications.

A study by Toles, Colón-Emeric, Naylor, Barroso, and Anderson (2016b) performs a similar analysis, as it deals with SNFs and older patients’ hospitalization. Here, the authors include multiple SNFs as examples of different transitional care services and compare their activities to each other. The research also highlights the fact that nurses performing transitional care use effective interventions to improve patients’ health and reduce the rates of readmissions. For instance, the scholars mention specialized transitional care personnel whose duties include pre and postdischarge assessment and preparation of patients. Self-education for patients and accessible discharge records are also needed.

The study argues that some of the leading problems of transitional nursing are the lack of clarity in providing services, unclear description of nurses’ duties, and poor structure of the organization’s support for workers (Toles et al., 2016b). Hospitals and other establishments often fail to sustain transitional care staff and offer limited resources for their work. The addition of more members also becomes hard in these settings, which further complicates the job of transitional nurses. In conclusion, the authors offer multiple approaches to improving transitional care, such as proper staff training, well-designed routines based on collaboration and discussion, specialized tools for regular activities, and the simplification of the informational flow between care delivery teams.

O’Brien et al. (2017) also explore the transitional care process for older patients. The purpose of this article lies in finding the shortcomings of ambulatory transitional care. In this case, researchers interview both patients and employees in order to learn about their experiences with transitional nursing. The study reveals a number of similarities between the experiences of multiple individuals. First of all, the process of providing patients with necessary information about their discharge is either lacking information or structure. Nurse and patients do not communicate well or often enough to make patients confident in their knowledge. Nursing specialists and care delivery teams also often fail to exchange all pertinent data about patients, which complicates the process of transition from one facility to another. Therefore, this finding supports the idea that nursing staff and other personnel do not understand the notions of transitional care correctly and should be appropriately trained.

Another problem pointed out by O’Brien et al. (2017) is the inconsistency of transport and staff availability, which makes patients wait for their transition for long periods of time. Thus, it is possible to assume that medical establishments do not invest enough funds into transitional care, which limits the number of available vehicles and specialists. Such long waiting times lead to another adverse outcome – increased levels of distress among patients. Older individuals who have to wait for their transportation for several hours may experience anxiety, which can negatively influence their health. Therefore, improper transitional care can have more adverse effects that undermine their healing process.

An article by Verhaegh et al. (2014) presents the idea of improving transitional care as a way to prevent hospital readmissions for patients with complicated and chronic conditions. The authors state that by creating useful transitional care interventions, hospitals can reduce the rate of preventable readmissions. They also outline a number of organizational aspects that worsen their performance, including the lack of standardization for discharge procedures and miscommunication between care providers in hospitals and primary care (Verhaegh et al., 2014). Here, transitional care is seen as a way to reduce the possibility of complications that can lead to a patient needing readmission. The authors analyze multiple health care systems and focus on both long-term and short-term outcomes. The study finds that transitional care can significantly improve long-term outcomes of patients if its interventions are intensive and patient-centered. Communication between nurses and care teams is vital for patient health, as well. Therefore, the significance of transitional care can be proven.

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A recent study by Storm, Schulz, and Aase (2018) evaluate the benefits of an inter-organizational intervention for transitional care that centers on patient safety and staff collaboration. The authors base their research on the problems that patients can have during their transition between different locations. These issues can include the lack of safety of patients’ personal information, incompetent staff, unorganized working process, and others (Storm et al., 2018). Thus, the researcher’s design an educational approach to improving transitional care, which is called “Meeting Point” and is concerned with training the hospital staff on the topic of patient safety culture. It includes various seminars and discussions for employees who perform transitional care. During this course, nurses and other professionals learn about the risk factors and patient perspectives of transitional care.

The results of implementing this intervention are evaluated in the form of questionnaires and follow-up discussions. Its outcomes included an increased number of employed nurses for transitional care, installation of screens with informative resources for patients, systematization of activities for electronic messaging, and overall improvement of nurses’ awareness about patients’ main problems linked to transitional care (Storm et al., 2018). The authors state that this intervention can bring “small but significant changes” to hospitals (Storm et al., 2018, p. e017852). Future improvements are also possible if clinics focus on transitional care more than before.


In order to answer all of the established research questions, it is essential to choose a proper methodology for this study. The central question, which is concerned with finding the primary problem of transitional nursing, requires a significant amount of information. This data can be collected from nurses performing transitional services and other members of the care delivery team. Therefore, the most appropriate methodology for this project is a qualitative approach with a focus on interviewing participants. This method allows one to collect useful and detailed information directly from the interested parties. Nurses working in transitional care have sufficient experience and knowledge to assess their position in the medical establishment and point out the main flaws in the care delivery process. Moreover, the method of questionnaires can give one an opportunity to gather information about possible improvements in transitional nursing. This qualitative approach can yield various results that will be presented in a list of possible answers to the outlined research questions.

The option of choosing questionnaires also allows one to utilize the Internet as a way to attract more participants. Therefore, one can create a system for sending and receiving forms through the Internet. Here, it becomes the primary tool needed for research, as it acts as a platform for communication and answer recording. The sampling methodology for the proposed questionnaire is non-randomized stratified sampling, as the research topic requires gathering information from individuals with a shared characteristic. All participants have to be working nurses with possible experience in transitional care. Here, this sampling method is important because it includes persons who are interested in improving the system of transitional care and can adequately assess its current state.


O’Brien, A. P., Giles, M., Corbett, L., Wagener, S., Ross, L., Bantawa, K.,… McNeil, K. (2017). Exploring the ambulatory transitional care experience from residential aged care facilities (RACF) to ambulatory care services. GSTF Journal of Nursing and Health Care (JNHC), 3(1), 48-57.

Storm, M., Schulz, J., & Aase, K. (2018). Patient safety in transitional care of the elderly: Effects of a quasi-experimental interorganisational educational intervention. BMJ Open, 8(1), e017852.

Toles, M., Colón-Emeric, C., Asafu-Adjei, J., Moreton, E., & Hanson, L. C. (2016a). Transitional care of older adults in skilled nursing facilities: A systematic review. Geriatric Nursing, 37(4), 296-301.

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Toles, M., Colón-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. (2016b). Transitional care in skilled nursing facilities: A multiple case study. BMC Health Services Research, 16(1), 186.

Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs, 33(9), 1531-1539.

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