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Transitional Care: Nursing Research in Design Phase

Transitional care involves actions by health care professionals to ensure coordination and continuity of care for their clients. Nurses play an essential role in ensuring the quality of medical care for chronically ill patients since they have information about the goals of treatment, patient preferences, and clinical status. Based on these data, they can effectively address the patient’s needs and provide education and support when necessary (Buurman et al., 2016). The purpose of the design phase is to conduct a literature review on transitional care as applied to chronically ill patients and outline the desired research methodology.

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Literature Review

It is worth noting that the goal of transitional care is to prevent the readmission of patients to a hospital and improve their self-efficiency through education (Buurman et al., 2016). If this aspect of care is ineffective, it may result in medical errors and poor communication between service providers or among people providing care to the individual (Rivera, DeCherrie, & Chun, 2018). The adverse effects of poor transitional care include the recurrence of symptoms of the disease, temporary disability, and other serious consequences (Albert, 2016; Loeffler, 2016). Also, due to ineffective care, patients may be readmitted to the hospital, which is an undesirable event for the institution (Czarnecki et al., 2019). The reason behind it is connected to the fact that readmissions imply inefficient use of resources for organizations.

Methodology and Design

The research will be carried out as a systematic review to synthesize evidence available on the topic of transitional care as applied to patients experiencing chronic illnesses such as diabetes and so on. The study will examine randomized control trials available from electronic medical databases and other online sources (Gray, Grove, & Sutherland, 2017). The goal of this part of the research will be to identify effective interventions and contrast them with standard practices and procedures. In addition, the researcher will interview nurses functioning in the hospital environment to specify expected hospital discharge and compare these activities with those found during the evidence synthesis. After that, the investigator will propose recommendations for practice and outline new perspectives in research.

For the purposes of the systematic review, around eight databases will be searched, including ProQuest, CINAHL, Medline, Cochrane, and other resources. Peer-reviewed articles will be considered to find the latest evidence on the topic and outline the best practice (Gray et al., 2017). Additionally, the researcher will conduct a series of interviews with nurses working with chronically ill patients to identify practices currently employed by healthcare specialists. This way, the results of qualitative research will be reinforced through naturalistic observations.

Sampling Methodology

It is expected that around 350-400 articles will be readily available from different databases. They will be further screened based on the inclusion criteria (Gray et al., 2017). Notably, only the latest evidence, which discusses the provision of transitional care to chronically ill patients, will be included. The risk of bias will be considered when selecting the material. In terms of interviews, both hospital discharge planning and in-home follow-up may be considered.

Necessary Tools

Several tools will be used to screen, extract, and systematize data received during the research. In particular, such a tool as EndNote will be used to handle bibliographic references and avoid reviewing duplicate articles. Alternatively, the investigator may use Covidence instead or along with EndNote. This is a program that assists researchers in screening the abstracts and may be used to manage references. In addition, it is helpful in terms of evaluating the risk of bias and when extracting data from multiple sources (Gray et al., 2017). Microsoft Word will be used to systematize and structure the evidence from both literature synthesis and on-site interviews.


The study will be implemented in several steps, which are as follows:

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  • The researcher will determine the online sources and databases that will be used to search for articles;
  • It will be necessary to formulate the specific search strategy (keywords by which scientific texts will be filtered out);
  • The investigator will filter the publications according to previously outlined criteria and receive full-text articles;
  • An analysis of texts and an assessment of the methodological quality of individual articles will be carried out, taking into account their research design (Gray et al., 2017);
  • Analysis of evidence;
  • The researcher will conduct additional statistical analysis if necessary;
  • Synthesis of evidence;
  • Preparation of a systematic review of the evidence-based literature;
  • Conducting interviews in medical institutions;
  • Analysis of the data and systematization of the findings;
  • The researcher will compare the information obtained during the systematic review and interviews;
  • The investigator will systematize the conclusions, propose recommendations for practice, and outline new perspectives in research.


Thus, it can be concluded that the research project will center on the topic of transitional care as applied to chronically ill patients. The study will follow the design of a systematic review, and its findings will be reinforced through the analysis of evidence found during interviews with nurses currently providing transitional care to their patients. Notably, the researcher intends to provide recommendations for practice and identify areas that require further investigation.


Albert, N. M. (2016). A systematic review of transitional care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100-113.

Buurman, B. M., Parlevliet, J. L., Allore, H. G., Blok, W., van Deelen, B. A., van Charante, E. P. M.,… de Rooij, S. E. (2016). Comprehensive geriatric assessment and transitional care in acutely hospitalized patients: The transitional care bridge randomized clinical trial. JAMA Internal Medicine, 176(3), 302-309.

Czarnecki, A., Austin, P. C., Fremes, S. E., Tu, J. V., Wijeysundera, H. C., & Ko, D. T. (2019). Association between transitional care factors and hospital readmission after transcatheter aortic valve replacement: A retrospective observational cohort study. BMC Cardiovascular Disorders, 19(23), 1-12.

Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove are the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Elsevier.

Loeffler, K. (2016). Geriatric intermediate care and transitional care for frailty-related patients. The European Journal of Public Health, 26(1), 426-427.

Rivera, V., DeCherrie, L. V., & Chun, A. (2018). Review of transitional care management and chronic care management codes for pulmonologists. Chest, 154(4), 972-977.

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