Transitional Care and Transitional Nursing Paper

Maybelis Garcia RN BSN Florida National University Nursing Research NGR 5110 Prof: Claudia Davis, Phd. RN- BC June 13, 2020 Running head: Literature review Literature review Generally, transitional care can be defined as the continuity of healthcare. The continuity is basically seen when a patient is moved from one healthcare to another or a home setting. The care given is seen to cater to those who need special attention during a period of chronic disease. Recent research done by the American geriatric’s society shows that transitional care is a set of conditions laid out to ensure that patients are coordinated and given continued healthcare. In addition, transitional care is purely based on the availability of healthcare practitioners, who, always, are well trained to meet the patient’s goals. According to (centers of medicare.2012), transitional care has more than twenty million Medicare beneficiaries involved, with thirty-seven percent recording chronic conditions. Better still, (Anderson, 2010), highlights multiple chronic diseases associated with risk factors. The risk factors highlighted are the likes of functional deficits and social barriers. All these barriers are known to bring about complexity when it comes to managing the healthcare sector. Transitional care, according to Berwick and Nolan (2008), concludes that care delivery approaches, always, approach the triple aim target, which, in return, enhances the patient experience and improved population health. Specifically, (Coleman and Boult 2007) provide information about evidence-based transitional care. In it, they state that it is a set of time-limited services, mostly delivered during acute illnesses between and across settings. Transitional care model The transitional care model focuses on improving care. In addition, transitional care aims at enhancing patients as well as family, caregiver outcomes, transitional care, just as stated by (Nylor, 2007), emphasizes on the identification of patients, design, health goals, and continuity of healthcare across settings and between those providing health services. However, considering 2 Running head: Literature review this section care is normally coordinated as well as delivered by highly trained nurses that are registered, who at all times is in collaboration with the patients. The information is according to (Naylor 2012), who adversely highlights that transitional care model supplements provided to patients in the hospital, is a substitute for care provided by professional nurses in patient homes. Evidence-based Findings from this study show that the transitional care model mostly benefits ill older adults. In addition, this helps improve the quality of life outcomes. The outcomes of these findings have brought about a conclusion that there is reduced hospitalization as well as overall healthcare cost. Transitional Care and Transitional Nursing Paper

The source of information is provided by (Naylor et al., 2004), who also states that the accounting for the additional cost of intervention, is reduced. Transitional care core components. Typically, the major parts of the core components of transitional care include engaging patients and maintenance of relationships and lastly assessing as well as managing risk and related symptoms (transitional care model, 2014). Methodology of the study The methodology of the study, in this case, is the use of proposition. It is so because schemes in most cases are not confirmed or refuted based on the evidence provided. Proposals, in most cases, are considered a bind to the study. For my transitional nursing essay, proposition mostly applied, bearing in mind that there was the use of inclusion in the literature review. In the described protocol, the proposition is developed from a practical theory that is related to a hospital care settings and researched literature. In my study, three propositions were developed to bring about a proposition study. The first one was my current research was based on a 3 Running head: Literature review previous review. The second one is that the transitional experience was influenced by practice experience. The third one is that practice experience was based on a type of education that varies and has responsibilities that are highly perceived. In the study, however, some research questions are included, and the research questions have been put in place. Design of study The design of the study mostly used is the presented case study. In this case, however, single descriptive qualitative is mainly considered. It is explained in that analysis involving the qualitative technique contains a single case that is supposed to uphold the outward transition extent of validity. The qualitative analysis that I carried out, aimed at representing transitional care at home. The case The case in this instance is that the boundaries set clarifies what was covered in the research study. The limitations, in this case, provide clarification of what was covered in the previous research study. Case definitions From the literature review provided in my study, there are three key terms identified. The first one is the transiting to practicing nurses that have just graduated together with a registered practical nurse. The transition to practice also covers holistic education provided that the role is highly professional. In my study however, there remains academic interest due to the relationship that exists amongst the retention of nurses and nurse practice transition. 4 Running head: Literature review -new graduate nurse: The design of the study has its time frame around new graduate nurses. The definition, in this case, has its inclusion of both the nurses’ designations within long term care and constituted in a time frame. The designations represented within long term care are permitted to practice development significantly. Better still, there is a need to practice theory. As far as a registered practical nurse is concerned, the professional designation of nurses is a title offered to nurses who have achieved transitional nursing standards. Transitional nursing involves clinical practice, managing resources, utilizing research, and advanced critical thinking. In addition, the patient’s condition influences the nursing care level that is appropriate. Sampling methodology In this case, the sampling methodology is supposed to be determined for every data that has been identified. The data in return, provides some vital priori; as seen in the case definition, the new graduate nurses offer purposive sampling strategies. The strategies are, however, utilized with desired samples based on the case and case binding. In transition nursing, however, there are many sapling methodologies. The first one is criterion sampling, and the second one was snowball sampling. Criterion sampling is used to exclude the new graduate nurses, who have worked in the long-term care, for more than one year. the other addition us of those who have held a nursing position before working as transitional nurses. Snowball, on the other hand, is used by the new graduate nurses who are, on most occasions, encouraged to share educative information with other nurses. The information shared is necessary, bearing in mind that it maximizes recruitment in the long transitional nursing on home-based care. Another example includes the inclusion criteria. Inclusion criteria sampling methodology is all about the identification of a geographic location. The identification is essential as it gives the statistics of home employed new graduate nurses. 5 Running head: Literature review Necessary tool The evidence-based care transition tool is the most appropriate one to use in this case. Under the same, falls the first category of health literacy assessment that has tools like the REALM SF, In-hospital IHI risk stratification, and REALM R. The second category of transition tool is the assessment of the health of each patient. Still, on the same, falls the EQ5D tool and the HHCAHPS tool. Transitional Care and Transitional Nursing Paper

HEALTH LITERACY ASSESSMENT -IHI risk stratification tool: Risk stratification involves pts of moderate risk as well as the pts of great risk. However, the level of High risk has patients who have failed teach-back, in other cases, the patients have minimal confidence level which enables them to do self-care at their places of residence. On the other hand, the level of moderate risk has family caregivers or patients with moderate confidence level, which enables them to do self-care at their places of residence. -Realm SF tool: The tool is made use of by making a REALM form. The strategies of using the same entail having patients fill out a form. In the way, the patients are expected to read every word and skip any unknown name to the patient. -Realm R tool The equipment is typically used for screening and to analyze the abilities of most adult patients. The tool is considered essential for it to helps caregivers to identify those patients who might be suffering from minimal literacy abilities. It is simply a test was done which involves 6 Running head: Literature review recognition of words and not an instrument to read. However, adults are the target audience, for they are mostly in a position of de-coding and pronouncing words. ASSESSMENT OF PATIENT’S HEALTH -ED5D tool: It is a self-completion booklet. The booklet has a section of one self-health question, where the patient is required to place a checkmark in one box or several checkboxes. Examples of questions involve usual activities, self-care, mobility, pain and discomfort, and lastly if there is a record of anxiety or depression. Still on the same, is the category rating thermometer. The rating thermometer is for office use only. -HHCAHPS tool: It is used by patients to rate their overall health. ALGORITHMS USED Algorithms mostly used are developed by the emergency medicine residency council. The target needs to be assessed through surveying. Besides, the method is used as a CORD task force. To get the results, there is the study design and population and the survey content and administration. The study design and people is an algorithm used to develop medical curricula that consist of six logical steps. The first step is problem identification, the second one is a target needs assessment, the third one is a general needs assessment, number four is the development of goals, and the final one is implementation. The survey is mostly presented as a TOC algorithm. The content and administration of the survey was designed using the needs of assessment. In the Algorithm, members of a particular group submit questions which are compiled and added to a survey. After the collection and compilation of data, a secure transitional care procedure is developed. 7 Running head: Literature review RESULTS The results of the algorithms used were then distributed through electronics and then were sampled different institution arrays. Also, the size of the institutions that participated ranged between 2-68, with approximately 90 patients who belonged to specialized care. The vital results that was obtained from the algorithms of special care administered to the aged people is represented by n to be equal to 147, the chairs represented by n to be equal to 99, and the residents together with nurses to be represented by n to be equal to 184 and n to be equal to 902 respectively. The informational parameters in the algorithms were considered important, for they mostly considered patients with current clinical conditions. The other things included in the algorithms is the completed and pending laboratory tests as well as examinations. 8 Running head: Literature review References Bixby, M. Brian, and Mary D. Naylor. “The transitional care model (TCM): hospital discharge screening criteria for high risk older adults.” Medsurg Nursing 19.1 (2010): 62-64. Hirschman, Karen B., et al. “Continuity of care: The transitional care model.” Online Journal of Issues in Nursing 20.3 (2015). Scholz, J., and J. Minaudo. “Registered nurse care coordination: Creating a preferred future for older adults with multimorbidity.” OJIN: The Online Journal of Issues in Nursing 20.3 (2015). Storm, Marianne, et al. “Quality in transitional care of the elderly: Key challenges and relevant improvement measures.” International journal of integrated care 14 (2014) 9 The Implementation Phase in Transitional Nursing Maybelis Garcia RN BSN Florida National University Prof: Claudia Davis, PhD. RN- BC July 07/2020 IMPLIMENTATION PHASE 2 The Implementation phase in Transitional Nursing The implementation phase involves comprehensive activities that are necessary during the patient care process. The stage requires more action and critical thinking to make decisions that are best suited for the patient. During the implementation phase, the nurse will be required to either take action or delegate duties between the healthcare team. The implementation phase encompasses various stages that end at documentation. Summarily, the implementation phase involves action, delegation, and documentation (Wassef et al., 2018). Another critical aspect of the implementation phase is that the patient and family have to be considered as a collaborative partner in the whole process to achieve positive outcomes. During a patient’s transitional care, a nurse will implement some actions that will enable the patient to get the best care once outside of the facility. Stage one: Preparing for implementation In Transitional Care For implementation to be successful, a nurse will have to do prior preparations. To prepare, there is a need to go through the patient’s implementation plan before starting the process. It is necessary to review the patient’s care plan and critically reflect on the medical comments and prescriptions, which will be critical in decision-making (Bingham & Gibson, 2017). The nurse will clarify the information in the care plan and ensure that everything is clear, correct, and accurate. The nurse will also do a self-evaluation to assess his or her suitability for the implementation. A nurse will seek assistance when he or she does not have enough knowledge and skill needed to implement the order when he or she is unable to carry out the task alone, or when the activity may have adverse consequences on the patient. The nurse will need to have a to-do list to ensure a welcome nation of activities. A nurse will also need a work plan that has well- IMPLIMENTATION PHASE 3 prioritized patient care. The caregiver will also need to identify the patients and familiarize themselves with specific patients and their rooms to avoid time wastage. The nurse will establish feedback points depending on the needs of the patient. When the instructions in the nursing order are constraining to the patient, the nurse will need to on the spot alter the activities to avoid affecting the patient adversely, depending on their response exhibited by the patient. When a nurse is organizing work, he or she will be required to schedule for feedback during the exercise, and after the activity (Khodadadzadeh, 2016). It is crucial to be actively engaged with the patient in order to have an understanding of their feelings. i. Preparing the equipment and supplies The nurse will also need to prepare the necessary equipment and supply during the implementation. All the supplies and equipment will need to be placed in the patient’s room for easy access when needed. When everything is put together in the patient’s room, it will relieve the patient from stress and anxiety. For example, if the nurse wants to catheterize a patient, it would be necessary to carry all the required equipment in case of an accident during the insertion. ii. Patient Preparation A patient is a human with feelings and needs to be prepared in advance of what is awaiting him or her. At this point, should prepare the patient by letting him or her know that they are about to be discharged or transferred to another care facility. Transitional Care and Transitional Nursing Paper

Preparing the patient physically and psychologically makes him or her ready to take the whole process positively. Before a nurse undertakes any action, he or she will be mandated to evaluate if the action is still necessary given the patient’s condition at that specific time Patient is leaving the hospital, the nurse will prepare him or her before being discharged. The nurse may need to dress the wounds of the patients if IMPLIMENTATION PHASE 4 there are any. Also, the nurse will provide the education necessary that the patient will need in his or her next care environment. Such education includes how to take medication and the type of diet to adhere to depending on the patient’s conditions. Stage Two: Action/Delegating stage After the nurse has prepared himself or herself, the equipment needed in the implementation, and preparing the patient, it is now the time to take the right action. The nursing actions encompass those that a nurse will do by themselves or delegates to another interdisciplinary team. Actions can also be collaborative, dependent, or independent (Riisgaard & Nexøe, 2017). It is crucial to facilitate the coordination of activities and the necessary nursing orders. All this are crucial to achieve hence having someone that is responsible to achieve a given task can help ensure that there are effective outcomes and also increased patient satisfaction. A nurse will need to have knowledge and skills relevant to the actions. Nursing interventions are varied. A nurse will use the most appropriate nursing intervention, depending on the current condition of the patient. If the patient who needs transitional care needs hypothermia treatment, the nurse will be required to warm the patient by removing his or her wet clothing. A nurse will need to be knowledgeable enough to apply all types of knowledge during the implementation phase (Riisgaard & Nexøe, 2017). A nurse will use personal, theoretical, practical, and ethical expertise in handling the patient. A nurse will utilize his or her psychomotor skills, Cognitive and interpersonal skills in performing the implementation activities: thinking, doing, and caring for the patient. For instance, when discharging a patient for transitional care to a different hospital, as a nurse, it is critical to give information to the next patient’s facility only with the consent of the IMPLIMENTATION PHASE 5 patient. The nurse will be obliged to provide education to the patient. The focus will be on discharge and to use home monitoring if the patient is going for home care. It is through this education that self-care will be enhanced something that would lead to significant health outcomes. In this case the chances of re-admission are reduced significantly. i. Enhancing patient participation and adherence Patient participation in the process involves the patient helping out in some minor activities during a procedure. For instance, a patient may decide to undress him or herself when receiving a shot. In adherence, the patient follows management routines to monitor his or her conditions, such as sticking to the right diet as advised by a physician. A nurse will promote corporation during treatment and therapy by providing the right education for the patient, assessing the patient’s knowledge of his or her condition, and evaluating the patient’s financial capability. A nurse will need to be sensitive to the cultural aspects of the patient (Ortiz, 2019). However, it is worth mentioning that information alone cannot change a person’s behavior, and as the caregiver, the nurse will need to put expectations on a reasonable scale. ii. Collaborative and Coordinated Care Patient care requires a nurse to collaborate and coordinate with other interdisciplinary teams to achieve better outcomes. A practice nurse will need to have the relevant skills needed to collaborate and coordinate in the implementation process. (a) Patient’s family The nurse will c …