Nursing Challenges in Transitional Care Research Paper

Nursing Challenges in Transitional Care Research Paper

Nursing Challenges in Transitional Care Research Paper


Final Submission

Students this project will allow you to formulate and hypothetically develop your own research project. The purpose of this project is for the student to complete all the different steps necessary to implement a nursing research project. This project will be subdivided into 4 different papers that will be submitted throughout the entire semester. The final paper will be the combination of the four areas. Please see separate file items for each phase specific instructions. Again follow APA style mandates.Paper will be submit it via turn it in. Nursing Challenges in Transitional Care Research Paper

The final submission is basically the combination of the other four phases into one paper. This paper will need to be corrected with all of the feedback provided form previous papers. Include on this paper a conclusion and learning experiences from the essentials and from the class.


• Essential I: Background for Practice from Sciences and Humanities o Recognizes that the master’s-prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics, public health, quality improvement, and organizational sciences for the continual improvement of nursing care across diverse settings.

• Essential II: Organizational and Systems Leadership o Recognizes that organizational and systems leadership are critical to the promotion of high quality and safe patient care. Leadership skills are needed that emphasize ethical and critical decision making, effective working relationships, and a systems-perspective.

• Essential III: Quality Improvement and Safety o Recognizes that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization.

• Essential IV: Translating and Integrating Scholarship into Practice o Recognizes that the master’s-prepared nurse applies research outcomes within the practice setting, resolves practice problems, works as a change agent, and disseminates results.

• Essential V: Informatics and Healthcare Technologies 5 o Recognizes that the master’s-prepared nurse uses patient-care technologies to deliver and enhance care and uses communication technologies to integrate and coordinate care.

• Essential VI: Health Policy and Advocacy o Recognizes that the master’s-prepared nurse is able to intervene at the system level through the policy development process and to employ advocacy strategies to influence health and health care.

• Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes o Recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care. Nursing Challenges in Transitional Care Research Paper

• Essential VIII: Clinical Prevention and Population Health for Improving Health o Recognizes that the master’s-prepared nurse applies and integrates broad, organizational, client-centered, and culturally appropriate concepts in the planning, delivery, management, and evaluation of evidence-based clinical prevention and population care and services to individuals, families, and aggregates/identified populations.

• Essential IX: Master’s-Level Nursing Practice o Recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that influences healthcare outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. . Nursing practice interventions include both direct and indirect care components. Nursing Challenges in Transitional Care Research Paper












Challenges in Transitional Care

Frank Calderon

Florida National University

Dr. Jorge Hirigoyen












Challenges in Transitional Care

Introduction to the Problem

The case of failure in transitional care for the elderly and the chronically ill patients shows the challenges in transitional care. Transitional nursing is the continuity of treatment of the patients during the movement from one health center to another or home.  The incidence re-hospitalization of people who have been released from the medical facilities to go home for recovery is high. According to Ortiz research, in 2015, 35.6% of hospital readmission within 30days of discharge is of elderly patients of age 75- 84. The authors indicate that this is due to the patients worsening instead of getting better.  Caregivers report that they do not know how to handle the patients that are left in their care. Storm and Aase (2014) elaborate that physicians say that elderly patients who have acute conditions are in vulnerable positions of breakdown if the proper transition is absent. This is after evaluating that some of the deaths reported of elderly patients in home-based and community- based care be caused by poor. Nursing Challenges in Transitional Care Research Paper

Ye and Quan (2016) point out that in 2012, China had the practice of the medical practitioners discontinuing patient’s care once the patient is discharged. The recovery care task was left with caregivers. This practice led to 30 percent of patient declining in their well-being and regular functioning after been released from the hospital especially the elderly. In the home-based care, they lacked professional monitoring. In addition to the issue in the transition of the elderly from the hospital to their home, the other failure is the transitional care within the medical setting.  Ortiz (2019) explains that the main case identified is medication mix-up and error during the movement of the patient emergency department to the intensive care unit. It also includes the surgical unit setting. Nursing Challenges in Transitional Care Research Paper


Problem Statement

Lack of specialized nursing intervention is the cause of the challenges in transitional care. It causes the readmission of elderly patients with acute illness.  The handoff of patients with no clear communication to the caregivers on how to take of them cause mishandling of the patient (Morphet & Williams, 2014). Most caregivers as well not trained on how to provide primary care to their patient. As a result, they develop other conditions, or their case elevates and hence the need to go back to the hospital. In some case, the patient may lack friends or family members to look after him or her. In such a situation, the patient requires a transitional nurse to fulfill his/her medical needs. The absence of one threatens the life and well-being of the patient. Nursing Challenges in Transitional Care Research Paper

The difficulties of transitional care within the medical setting are as a result of lack of specialized nurses who are skilled and knowledgeable about providing professional care. Storm and Aase (2014) illustrate that the issue of delay in the provision of therapy places the patient at risk.  This is a challenge that results because of unprofessional nurse handling the transfer of the patient from unit to another. A specialized nurse is aware of the importance of timely and complete communication. Poor transitional care in chronically ill people exists due to improper coordination between the emergency department nurse and the one in the ICU.  Ortiz (2019) asserts that lack of organization confuses the right therapy for the patient which in turn causes the delay in the recovery of the patient or the development of complications.

Furthermore, unlike a regular nurse, a specialized nurse provides quality transitional care. They are experienced, well-trained and knowledgeable in giving transitional care.  A general nurse will administer primary care for an ill person who is hospitalized. It is evident that the provision of transitional care by ordinary medical practitioners is the cause of low-quality care. This creates patient and caregiver dissatisfaction.

The significance of the problem to Nursing

The research problem is significant to nursing.  The problem is; lack of specialized nursing is the cause for the challenges in transition care.  It directly concerns the nursing profession. It raises awareness of the weakness of nursing in transitional care. It identifies that nursing service in transitional care is poor. Patients are sent off without continuity care from professionals till they fully recover.  Moreover, the wrong care is given to the patients when they are moved within hospitals from one setting to entity as nurses commonly provide the wrong medication.

The problem also informs the nurses their weakness in communication.  It implies that unspecialized nurse is not keen in providing timely and complete information to facilitate continuity care. It mainly raises concerns in nurses in units where that transfer takes place.  The problem as well illuminates to nurses that poor professional coordination between them is resulting in transitional care challenges since it hinders consultation and provision of information.

It similarly notifies the nurses their shortfall in performing specific crucial nursing roles. The first one is ensuring the patient with no caregiver receives transitional care from them. Secondly, it is educating the caregivers on how to handle the patients. In addition to informing the nurses on the weak areas, it is enlightening them how to improve the nursing job. It is asserted that specializing in transition care will enhance their task of providing care to patients. Therefore, it is recommended that nurses who deal with transitional care get additional education to gain skill. Finally, the problem cautions the nurses on the impact of lack of knowledge and expertise. It shows that the implications are detrimental to the patients whose health are already vulnerable.

Purpose of the Research

The purpose of the research is to improve the quality of transitional care. There is a lot of research about the quality of the general health in the hospital. Therefore, various stakeholders have invested in facilitating quality treatment. Nevertheless, the issue of transitional care has not little study and as a result their no broad awareness of the matter concerning transitional care, its challenges, and importance. This, in return, has led to little attention from the government, physicians and donor, individuals who can contribute to promoting good transitional care. This prompted my research on challenges in transitional care to implore the health stakeholders to look into the issue and promote quality transitional care.

Furthermore, I considered research into the challenges of transitional care would be a way to inform the nurses on the areas of their weakness and as a result, encourage them to improve. It will eventually translate to quality transitional care. My research exposes the challenges faced in transitional care and the problem which is lack of specialized nurses. In addition to the nurses, it also creates awareness for the caregiver and relevance of seeking help from transitional nurses. My study likewise enlightens the medical trainers on the significance of including transitional care in the nursing curriculum. Consequently, all nurses will have basic knowledge of rendering such care

Finally, through researching the subject on transitional care, I offer a platform for further research into the area. Therefore, it will promote a better understanding of the issues facing transitional care. This helps the stakeholders to see the severity of the issue and provide assistance.  Further research will likewise suggest better solutions to address the problem facing transitional care.


Research Questions

 What is the impact of unspecialized nursing in transitional care?

Why do unspecialized nurses promote low-quality transitional care?

What are the pros and cons of specialized nursing versus general nursing?

Master’s Essentials Alignment with My Topic

Master’s essentials align with my topic. It concurs with what my topic implies.  The second essential indicates that organizational and system leadership is crucial in quality and safe patient care.  My topic, on the other hand, illuminates on the importance of leadership in patient care as some of the challenges like communication and corporation are due to lack of leadership.  Master’s essential III as well support the topic problem which suggests that lack of specialized nurses is the cause of challenges. The essential state that master-level nurses are aware that quality care goes hand in hand with the methods and tools used. Similarly, the topic indicates that the use of unspecialized nurses who have no master is the cause of the low-quality transitional care.

Essential VII, interprofessional collaboration asserts that masters prepared nurse is a leader and member of the team who can communicate, cooperate and consult with other professionals. Similarly, the topic agrees as it suggests that the challenges of lack of communication, coordination, and consultation. It adds that this due to the use of unspecialized nurses implying that nurses with maser can overcome the challenges.

The topic as well matches with essential IX. It is concerned with master-level practice. It states that nurses with master’s level have scientific knowledge and the capability to apply it into practice. My topic suggests that unspecialized nurses are not as competent as the specialized ones who have a master’s degree. Therefore, they pose challenges in transitional care which wouldn’t have been the case if specialized nurses conducted the care. This essential as well claim that master’s prepared nurses can influence positive healthcare result. The topic echoes that specialized nurses perform transitional care better compared to general nurses.




















Morphet, J., Griffiths, D. L., Innes, K., Crawford, K., Crow, S., & Williams, A. (2014). Shortfalls in residents’ transfer documentation: Challenges for emergency department staff. Australasian Emergency Nursing Journal17(3), 98-105.

Ortiz, M. R. (2019). Transitional Care: Nursing Knowledge and Policy Implications. Nursing Science Quarterly32(1), 73-77.

Storm, M., Siemsen, I. M., Laugaland, K., Dyrstad, D., & Aase, K. (2014). Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International Journal of Integrated Care14(2).

Ye, Z. J., Liu, M. L., Cai, R. Q., Zhong, M. X., Huang, H., Liang, M. Z., & Quan, X. M. (2016). Development of the Transitional Care Model for nursing care in Mainland China: a literature review. International journal of nursing sciences3(1), 113-130.


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