Transitional Care Model and Its Phases


Identifying productive ways to improve transitional care for older adults with chronic diseases in complex with other risk factors such as social barriers or issues of managing their care needs is essential for increasing the productivity, and for decreasing the costs of healthcare. One model that proved to be effective, giving decent care to these people while reducing costs, is the Transitional Care Model (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). According to Hirschman et al. (2015), “the Transitional Care Model is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians” (para. 1).

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The Transitional Care Model includes nine interconnected core components intended to provide holistic care. One of these nine components is staffing (Hirschman et al., 2015). Mensik (2014) states that appropriate staffing is “a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation” (para. 2). There are two types of staffing: centralized and decentralized. Centralized staffing implies the responsibility of one department for staffing all units. Decentralized staffing, on the contrary, is based on the determination of unit leaders. Charge nurses determine the number of staff needed before and during work hours (Mensik, 2014).

Staffing can be conditionally divided into three models which are insufficient separately. There is no universal model. Most healthcare organizations use a set of models to address their needs. The budget-based staffing model implies scheduling nursing staff by hours per patient day. In the nurse-patient ratio model, the number of nursing staff per number of patients defines staffing levels. The patient acuity model determines staffing levels according to patients’ personal needs and characteristics (Mensik, 2014).

Significance of the Problem to Nursing

A high level of care is the main goal in the world’s health care system. Some of the most important issues that need to be addressed are the growth of the aging population and combating diseases. To reach the goal, health care systems all over the world have to develop new approaches to care. The nurse staffing is one of the promising approaches that has already proved to be effective (Cho et al., 2016).

Purpose of Research

Due to the efficiency of nurse staffing, the approach must be analyzed. It is necessary to analyze staffing and identify how it can improve. Also, the research must consider nurse staffing in the context of technological development.

Research Questions

The key questions of the research that must be addressed:

  1. The impact of nurse staffing on the world’s healthcare;
  2. Personal approach and forming a nurse-patient relationship;
  3. Effective use of modern technologies in nurse staffing.

Master’s Essentials

The nurse staffing is inextricably linked to the Essentials of Master’s Education in Nursing. Nurses have direct contact with patients, thus becoming a key component in improving the healthcare system. The Essentials that refer to the research are:

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  • Information Management and Healthcare Technologies;
  • Political and Financial Aspects;
  • Clinical Prevention and Population Health.


The Transitional Care Model is a nurse-led intervention targeting older adults at the risk of poor outcomes as they move across healthcare settings and between clinicians. One of the nine components intended to provide sufficient care is nurse staffing. Over the past years, staffing has proved to be efficient. Nurse staffing is complex. However, proper staffing can improve the healthcare system and reduce its costs. The research must analyze staffing and identify the ways to improve its contribution to the development of the world’s healthcare system.


Cho, E., Lee, N. J., Kim, E. Y., Kim, S., Lee, K., Park, K. O., & Sung, Y. H. (2016). Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: A cross-sectional study. International Journal of Nursing Studies, 60, 263-271.

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The transitional care model. OJIN: The Online Journal of Issues in Nursing, 20(3).

Mensik, J. (2014). What every nurse should know about staffing. American Nurse Today, 9(2).

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