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Challenges in Transitional Care

Challenges in Transitional Care

Florida National University

Robert Alonso

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May 21, 2019

Introduction to the Problem

Increasing cases of patient readmissions as soon as they are discharged from hospitals have been on the rise thus indicating existing challenges in the provision of transitional care. Transitional care refers to the provision of continuous treatment to the patients as they move from one health care facility to the next or from the health facilities to their homes. According to a study conducted by Ortiz in 2015, it was established that “35.6% of hospital re-admissions within 30 days of discharge are of elderly patients aged 75-84” (Ortiz, 2019). These statistics indicate existing disparities in the provision of transitional care thus resulting in the worsened conditions of the patients as soon as they go home. Ortiz nonetheless establishes that most caregivers admit to not having adequate knowledge and experience on how to deal with the patients as soon as they are discharged from hospitals (Ortiz, 2019). In most cases, elderly patients suffering from acute conditions tend to be the most vulnerable and easily fall ill once transitional care is missing. Further according to Storm, “A majority of the deaths involving elderly patients in home-based and community-based care were as a result of lack of additional transitional care” (Storm et. al., 2014). Similar results are echoed by Ye et. al., (2016), where in China policies were introduced in 2012, hindering the provision of transitional care to patients by the nurses, and as a result the practice saw at least 33% of the elderly patients decline in their overall well-being and functioning once left under the care of their caregivers. Therefore, such statistics indicate that home-based care is often marked by a lack of professional monitoring and also the transition from a medical setting to a home setting often results in medication mix-up which negatively imposes on the health of the elderly patients.

Clearly Identify the Problem

Transitional care is marked by a lack of specialized nursing interventions which results to the high rates of hospital readmissions especially among the elderly patients suffering from acute conditions. Also, there lacks clear communication during the handing off of the patients to the caregivers, hence resulting in increased confusion on the part of the care givers on how to take care of the patients which results in their worsening conditions (Morphet et. al., 2014). Additionally, a majority of the caregivers are not adequately trained on how to provide primary care to their patients and hence when left in their care, their condition does not get any better forcing them to be readmitted to hospitals. In other cases, the patients may lack caregivers to look after them hence requiring a present transitional nurse to help meet their medical needs, and once these nurses are absent then the well-being of the patients is compromised (Morphet et. al., 2014).

The existing challenges in transitional care are largely brought about by the lack of specialized nurses with skills and knowledge on professional transitional nursing care. According to Storm et. al., (2014), the health and well-being of the patients is threatened once there exist inconsistencies in the provision of transitional care. In most cases, unspecialized nurses are left to handle the transfer of the patients from one facility to the next which makes their situation worse, since such nurses are unaware of the significance of timely and comprehensive communication during the transition period. Moreover, when dealing with unspecialized nurses, there exist inconsistencies in the emergency department nurses and those in the ICU hence worsening the transition phase. Hence, the existence of unspecialized nurses adds to more confusion on the type of therapy required by the patients in their recovery phase hence resulting in more complications (Ortiz, 2019). Thus, the existence of specialized nurses in transitional care is key in ensuring the provision of high-quality transitional care and also in promoting the well-being of the patients.

Significance of the Problem to Nursing

The problem on transition care is significant to nursing since it illustrates the need for specialized nursing care as a means to overcome the existing inadequacies in transition care. Also, the problem is rooted in the nursing profession as it seeks to increase awareness on the importance of specialized nursing care during transitional care. The problem further establishes that the current nursing services involved in transition care are inadequate and that often patients are often sent home without lack of continuity care from professionals. The problem is also significant since it informs of the weaknesses in nursing communication, illustrating inconsistencies in the provision of comprehensive information to foster continuity care. Also, the problem makes it evident that poor professional coordination among the nurses comes in the way of transitional care hindering effective consultation of the provision of information among the nurses and to the caregivers. Consequently, the problem helps to illuminate the challenges encountered by nurses when providing their nursing roles among them ensuring that patients with no caregivers receive transitional care from them and also informing the caregivers on how to deal with patients. The problem is hence important in informing nurses on their shortcomings and informing them on how to enhance their nursing roles. Addressing transition care will help to improve the role of the nurses in providing care for their patients and hence it is essential that nurses acquire additional skills and education on how to provide transitional care to patients.

Purpose of the Research

The main purpose of the research is to enhance the quality of transitional care. Previous studies focused merely on the quality of health care provided to the general population while omitting the issues surrounding transitional care and as a result there lacks knowledge and awareness on transitional care hence resulting in the increased rates of patient readmissions. Therefore, my research on the topic is intended to provide adequate knowledge of the issues surrounding transitional care and to bring attention to the stakeholders on the significance of investing in the issue. Also, the research is intended to enlighten the nurses on their areas of weaknesses and to enlighten them on how they can improve their provision of transitional care. Another key purpose of the research is to push for the inclusion of transitional care in the nursing curriculum to help impact all nurses with adequate knowledge on how to go about the issue. Lastly, the research aims to create a platform for more future research on the same hence raising awareness on the severity of the issues on transitional care

Research Questions

The research will answer the following questions:

  1. What are the main challenges facing transitional care?
  2. How does unspecialized nursing impact on transitional care?
  3. What is the importance of specialized nursing in the provision of transitional care?

Master’s Essentials that Align with my Topic

Different master’s essentials align with my topic. For example, Essential II establishes that the quality of patient care is enhanced by effective organizational leadership, and in my topic, I have highlighted how challenges in leadership like communication and nurses’ corporation negatively impose on the patient well-being. Also, Essentials III aligns with my topic where it points out that inadequate specialized nursing is the root cause of all the shortcomings in the provision of health care and that master-level nurses should always be present in any nursing facility as they are fully aware on how to handle different patient needs. Likewise, my topic indicates that unspecialized nurses result in the provision of low-quality transitional care. Lastly, my topic aligns with Essential IX, which establishes that the master’s degree level nurses tend to have scientific understanding and also know how best to apply the knowledge to practice. The Essential further notes that such nurses can quickly influence the realization of positive health care outcomes. Similarly, my topic notes that unspecialized nurses cannot compare to the specialized nurses with a master’s education, where the unspecialized nurses are not well vast on the importance of transitional care while the specialized nurses can quickly influence better transitional care results because of their level of expertise and knowledge.


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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