The transitional model of nursing care included a wide variety of services and processes targeted at ensuring the secure and timely transfer of individuals between different levels of healthcare or health care settings. One of the most critical challenges in this context is ensuring the safety and well-being of patients of older age during their transitions because they have several chronic conditions and complicated regimens of therapy. Thus, the issue of guaranteeing high-quality care for older patients represents the central problem for the current exploration. A growing body of evidence on transitional care suggests that older patients are more likely to experience breakdowns in care and therefore have a greater need for high-quality transitional care (Naylor & Keating, 2009). The inadequate ‘handoff’ of older patients from healthcare facilities to their families or other facilities has been shown to be linked to adverse health outcomes, low satisfaction with healthcare services, and increased rates of hospitalization.
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The poor quality of transitional care provided by nurses to older patients represents a key challenge within the given health care problem. Several detrimental factors contribute to the gaps in the critical transitions of older adults. They include but are not limited to inadequate communication between healthcare providers, the incomplete sharing of patient information, the lack of effective communication with caregivers from family, the absence of access to essential services, and lack of a simple point person for ensuring care continuity. Thus, it is imperative to ensure that the factors are maintained on a high level in order to ensure that older patients receive appropriate transitional care to address their health needs and challenges.
The issue of inadequate transitional care provided to older patients is significant to nursing as a practice because it decreases satisfaction with care and leads to adverse health outcomes for the target population. Over time, specialists in the field of the nursing practice have been working on developing positive methods for the handoff and transition of older patients within transitional care. However, limitations persist in the handoffs and transitions of older patients, primarily as related to nurses’ perceptions of the care that they should provide (Dale & Hvalvik, 2013). The culture of patient safety in transitional care implied inter-organizational features represents significant challenges to nurses because of the need to combine the culture of patient safety and the culture characterizing specific health care facilities. Staff operating at hospitals and nursing homes is expected to collaborate with other participants of the care process to ensure the successful organization of reasonable care (Storm, Schulz, & Aase, 2018). This means that the nursing practice should be improved on the inter-organizational level in regards to addressing the challenges of transitional care for older patients.
The principal purpose of the research on the identified issue is to determine the limitations that exist in the delivery of transitional care as related to older patients and identify methods of eliminating them. Studying both nurses’ and patients’ perceptions of the limitations of transitional care is essential for determining the challenges that prevent nurses from providing the quality of care that patients need. In addition, it is vital to involve the perspective of family caregivers because they also play a role in transitional care services. This aspect of research is essential because little attention has been paid to the distinct needs and perspectives of caregivers. For this reason, they have rated their engagement in the decision-making within transitional care as inferior. This means that further complications with the delivery of transitional care to older patients will emerge.
In studying the limitations associated with transitional care for older patients, it is essential to answer several questions. The list of research questions presented below considers the perspectives of different participants in the transitional care process. Based on the feedback given by various members of the care process, it is expected to differentiate between multiple limitations of transitional nursing as well as develop recommendations for overcoming the identified challenges. The research questions are the following:
- What are the patients’ perceptions of the limitations in transitional care?
- What are the nurses’ perceptions of the challenges of transitional care?
- What are the caregivers’ perceptions of their involvement in transitional care?
- What are the fundamental limitations in providing high-quality transitional care to patients?
- Based on the findings, what are the methods of improving the delivery of transitional care to older patients?
As aligned with the Master’s Essentials in Nursing, the chosen research topic is expected to align with several essentials. For example, in the area of Quality Improvement and Safety, the study supports the need to recognize that nurses should be knowledgeable in the tools, performance measures, and standards related to quality as well as apply them to the process of care (American Association of College of Nursing, 2011). Interprofessional Collaboration for Improving Patient and Population Health Outcomes is another important essential that aligns with the planned study because of the need for nurses to become advocates of their patients, and transitional care is one of the areas of nursing that requires such support.
American Association of Colleges of Nursing. (2011). The essentials of Master’s education in nursing. Web.
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Dale, B., & Hvalvik, S. (2013). Administration of care to older patients in transition from hospital to home care services: home nursing leaders’ experiences. Journal of Multidisciplinary Healthcare, 6, 379-389.
Naylor, M., & Keating, S. (2009). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108(Suppl 9), 53-63.
Storm, M., Schulz, J., & Aase, K. (2018). Patient safety in transitional care of the elderly: effects of a quasi-experimental inter-organizational educational intervention. BMJ Open, 8(1), e017852.