Transitional Care Interventions: Planning a Nursing Study


The fight against chronic diseases is an urgent problem of modern medicine, and the task of comprehensive care for patients with constant complications lies on the nursing staff. One of the issues that deserve discussion is the too high level of readmission among those who spend much time in medical institutions. The practice of transitional care implies continuous control over the well-being of patients both in healthcare facilities and at home.

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Therefore, it is essential to reduce the number of readmissions so that people with chronic diseases could undergo treatment in stages and could not interrupt the treatment process. In order to narrow the range of research, a specific health problem can be addressed. In particular, it may be chronic heart failure (CHF), a disease that affects a large number of people and is the cause of constant complaints. The chance of reducing readmission rates by providing comprehensive and timely care for patients with CHF opens up positive prospects for nursing practice and allows patients to recover faster.

Problem Identification

Despite efforts taken by medical personnel, readmissions in medical facilities are a regular phenomenon. According to Feltner et al. (2014), “nearly 25% of patients hospitalized with heart failure (HF) are readmitted within 30 days” (p. 774). At the same time, not only heart diseases but also other chronic illnesses also deserve attention. The lower the level of readmission is, the more productive will be the practice of physicians. Therefore, this topic deserves discussion, and relevant and appropriate interventions are needed.

Also, the situation is complicated by some limitations, which are manifested in the interventions of this type. As Feltner et al. (2014) remark, all people have distinctive degrees of the disease and suffer from it differently. Moreover, in the case of interventions, the level of physical fitness inpatients may also vary, and those procedures that could be prescribed as maintenance therapy are not always appropriate. Accordingly, the problem is complicated by the fact that an individual approach to the consideration of all the cases of CHF is necessary, and the participation of staff in controlling the peculiarities of interventions is crucial.

Significance of the Problem to Nursing

The nursing staff is interested in solving the problem of readmissions. Junior medical employees involved in transitional care are forced to pay much attention to patients. If readmissions happen, it not only negatively affects the rating of the medical institution but also entails the responsibility of personnel. Moreover, as Verhaegh et al. (2014) argue, “to reduce short-term readmissions, transitional care should consist of high-intensity interventions that include care coordination by a nurse” (p. 1531). Therefore, the junior medical staff is interested in improving the current situation.

Purpose of the Research

The purpose of this research is to identify potential interventions that may be helpful in addressing the high level of readmissions for patients with CHF. Answers should be given to questions regarding the application of possible practices by nursing staff and suitable methods. Also, medical specialists’ important skills should be mentioned in order to determine the level of staff training and develop appropriate work strategies.

As justification measures, appropriate reasons should be mentioned to determine the extent of the problem and the rationality of applying specific procedures. Search for evidence is a prerequisite for comprehensive and supportive care. Otherwise, the objectives do not allow the problem to be addressed completely, despite the identification of the task list, and no significant achievements can be achieved because of an improperly compiled work course.

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Research Questions

Applying relevant academic literature may help to find the appropriate ways of solving the problem in question. The identification of the spectrum of work depends largely on the goals and methodology. As research questions, the following ones can be used as a basis for conducting the study:

  1. What is the role of nurses in reducing the readmission rate among patients with CHF?
  2. What interventions can be effective for achieving positive results concerning the problem and finding potential measures to eliminate the issue?
  3. What transitional care conditions need to be maintained to ensure a higher treatment level and satisfaction with personal well-being among patients with CHF?

Master’s Essentials Regarding the Topic

In order to work effectively, medical employees’ important skills can be useful. According to Condon, Lycan, Duncan, and Bushnell (2016), the model of transitional care considered by the authors provides for “the use of Master’s prepared advance practice nurses” (p. 1602). The productive collaboration of experienced medical staff is a key to successful interventions aimed at reducing the number of readmissions and increasing the quality of treatment.

As Feltner et al. (2014) propose, all the stages of work, including information search, its evaluation, and other steps, should be carried out in cooperation to avoid personal bias or not to miss crucial information. The role of experienced healthcare personnel is to focus on the problem and find the best ways to solve it. Therefore, nurses’ valuable knowledge and relevant qualifications are prerequisites for starting the work process.


Condon, C., Lycan, S., Duncan, P., & Bushnell, C. (2016). Reducing readmissions after stroke with a structured nurse practitioner/registered nurse transitional stroke program. Stroke, 47(6), 1599-1604. Web.

Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J.,… Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Annals of Internal Medicine, 160(11), 774-784. Web.

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. Web.

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"Transitional Care Interventions: Planning a Nursing Study." StudyCorgi, 12 July 2021,

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StudyCorgi. 2021. "Transitional Care Interventions: Planning a Nursing Study." July 12, 2021.


StudyCorgi. (2021) 'Transitional Care Interventions: Planning a Nursing Study'. 12 July.

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