Phase 1: Introduction to Transitional Nursing

Introduction

Transitional care refers to coordinating and continuing health care during movements from one healthcare setting to another or home. It is viewed both as negative and positive by the nurses depending on the scenario. It is positive if a patient is discharged from the hospital and heads home to recover and enjoy good health. On the other hand, it is negative if a patient is readmitted to the hospital a few days after discharge. This can be due to illnesses that could otherwise be prevented had the patient remained at the hospital. During transitions of care, a nurse or a well-trained practitioner with current information on the patient’s health records and preferences should accompany the patient to make a follow-up on the condition of the patient after the transition.

It is suggested that transferring a patient back home can accelerate the rate at which the patient recovers from the illness. This is because while at home, the patient is provided with the most advantageous mode of care and is less likely to contract infections from other patients with infectious diseases. Is this point valid, or is it just a belief? Duddridge, 2001, has proven the social interaction concept with newborn babies who record quick recovery rates when they have family members to interact with. Wassef, 2018, has also found transitional care advantageous in the improvement of health among the elderly. However, it is essential to investigate and prove the validity of the statement in average patients before making any conclusions.

The Problem

Different researchers have investigated quality issues that affect transitional care. This study, therefore, focuses on factors such as the context, competence of health Running Head: Transitional Nursing 3 practitioners accompanying or making a follow-up with the patient transferred from hospital to home, how information is exchanged, and the patient’s involvement. In the case of context, this study identifies how different environments influence the recovery of the patient. In particular, the settings selected are the rural areas and urban areas. The competence of the health care practitioner will be determined by experience and the methods used to assess the improvement of the patient. This study will also evaluate how information is exchanged between the patient’s caretaker and the nurse when making a follow-up. It involves oral, electronic, or written methods of transmitting the information. Participation of the patients was evaluated depending on the relevance of the information supplied by the patients concerning their health. The problem is that many variables exist in the case of transitional care. This study will, therefore, be useful in making conclusions so that we do not end up blaming patient readmission on the incompetence of the nurse when the problem was the environment involved or such cases.

Significance of the Problem to Nursing

Transitional nursing helps reduce the number of patients in the hospitals, thus avoid congestions. Congestion is the state in which activities are slowed by the under-capacity of vital resources. Reducing the rate of readmission is, however, challenging without understanding the types of support and guidance that the patient requires after discharge. Without proper coaching, readmission, or worse events can occur. Researchers have found a connection between congestion and the mortality rates for all hospitals. Death of patients can also occur due to a lack of efficient care. A hospital is supposed to discharge a patient if the patient does not require the need for hospital care anymore. It does not, however, mean that one is fully recovered. Releasing can also be done Running Head: Transitional Nursing 4 to reduce costs if the patient is highly likely to recover while at home. Discharging also avails the hospital bed for another patient. It is, therefore, critical that we find ways of improving the recovery environment of discharged patients so that we can increase the percentage of patients who recover after discharge and reduce readmission.

Purpose of the Research

Nursing is primarily involved with providing optimal care for patients, while transitional care is mainly engaged with continuity of health. Analysis of medical errors reveals that there are many gaps in health continuity. Carrying out a study on the safety of the patient increases our understanding of the provision of health care. This problem will help analyze the strategies that can reduce the rate of patient readmission to the hospital. It also helps explain post-discharge events that may cause adverse effects to the patient under transition care. It is difficult to predict the patients that will be readmitted after discharge or those that will experience adverse events. Studies have shown that some factors that can determine readmission include age and type of illness (Tappen, 2016). A minimal research has been done on the quality of life in such aspects as competence of the practitioner concerned or social support from loved ones. This Research is, therefore, vital as it analyzes these aspects that have for so long been ignored as minor influences during the recovery period. The results obtained from Research will be useful in solving practical problems and advocating for change in various practice settings. Furthermore, the application of communication technologies in promoting and delivering care will be required.

Research questions

Research mainly employed observations on various patients who had been discharged and were exposed to different environments during recovery. Background questions were used in the Research and mostly required general knowledge about the Research. The questions that had to be answered during the Research include the following.

What was the condition of the patients at the time they were discharged?

It is crucial to consider the health condition the patients were at the beginning of the Research to better gauge it with the situation after the Research. This will provide the rate at which the patients are recovering. Generally, the patients discharged did not have any significant complications. During the Research, the patients used in the study had minor fractures in their bones. Major illnesses were avoided to prevent jeopardizing the lives of patients. Furthermore, physical injuries are better to monitor in terms of recovery.

What conditions were the patients exposed to?

Special care was taken since the lives of patients were under my care. I, therefore, did not want to disclose them to adverse conditions. I generally used pairs. Each of the pair was exposed to contrasting conditions. For example, when studying the effects of the surrounding, one patient was exposed to a pleasant surrounding with beautiful sceneries while the other was enclosed in a dark room for most of the time. Similar scenarios were provided for testing the other aspects.

What were the health conditions of the patients after the study?

The case study lasted for two weeks, after which the patients underwent testing to evaluate how active the recovery period was. The finding was recorder for each pair regarding the doctor’s analysis after the test.

What were the findings?

While studying social interactions, it was found that the patient who interacted with the loved ones recovered quicker than the one left in isolation. The patient who’s a nurse had more years of experience recovered faster than the one whose nurse had less experience. This showed that in addition to theoretical knowledge of nursing, one has to acquire extra people skills for more competent to promote recovery of discharged patients. Pleasant surroundings also led to a quicker recovery of a patient. The patient in the rural area also recovered faster than the one in the urban area due to air and noise pollution in the metropolitan area.

Master’s essentials aligned with the Research

The Research required application of various essential skills of a nurse in a Master’s education level. The essentials include the use of both theoretical and practical knowledge acquired in multiple fields of study, such as public health. Incorporating theoretical knowledge into useful Research helped in the analysis and interpretation of the results to come up with a reasonable conclusion. Leadership and organization skills such as critical thinking and effective working relationships were essential as the Research involved working with patients and the cooperation of their families.

Phase 2: Literature Review and Research Methodology

Literature Review

Generally, transitional nursing 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 Rennke and Ranji (2015), 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. 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 (Rezapour-Nasrabad, 2018).

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 (Naylor et al., 2004), emphasizes on the identification of patients, design, health goals, and continuity of healthcare across settings and between those providing health services. However, considering 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 et al., 2004), 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. 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.

Methodology of the Study

The methodology of the study, in this case, is the use of propositions. 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 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.

-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.

Sampling Methodology

In transition nursing, 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. 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.

The sample for this study will be pre-established research works on transitional nursing and care. studies that will be used will be determined by the date and primary research methods. Literature published earlier than 2000 will not be used. These papers will also include abstracts.

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.

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 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 are 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.

Phase 3: The Implementation Phase in Transitional Nursing

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-

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. 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

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

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 readmission 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 contact the family of the patients and make them aware that their family member is about to be put under transitional care in a different setup. The nurse will

negotiate the budget for the patient with the family and listen to their financial concerns. The nurse, together with the patient and family the goals for the patient’s recovery

(b)    Liaising with the interdisciplinary team

The nurse liaises with the financial office so that they can prepare a bill for the patients. He also denies liability with the pharmacy, providing the right prescription that the patient needs on his or her way. The nurse will also notify the patient’s doctor so that the doctor prepares the patient for discharge.

The Final Stage: Documentation

Facilitating effective documentation is crucial and is the first step towards implementation. Giving care to the patient is not only enough but needs documentation to provide future references. A nurse has the mandate to document every process and activity regarding the patients and the nurse. The nurse will perform accurate data capture, which will provide relevant communication to two other interdisciplinary teams regarding the patient. The nurse’s summary will be necessary for evaluating the patient’s health status for better decision- making during transitional care. The nurse will write a discharge plan and write a report on patient discharge. The nurse will also write a discharge summary for the patient, which the doctor will acknowledge. Recording the patient data will start from the day of admission up to the point of discharge. Billing will be the last documentation that would be recorded.

Budget

For the implementation stage, there is need to set up a budget that would help ensure that the theirs is better implementation of care. A budget has to be set for the preparation of the equipment and supplies. Also, it is necessary for patient preparation. Also, it would be necessary

for enhancing patient participation and adherence. Finally, is a budget that would help cover the cost of liaising with interdisciplinary team.

Budget

TRANSITIONAL SCHEDULE

Phase 4:

Introduction

This case study results show that the quality of life of a patient under transitional care involves multiple factors. These results show that under different conditions, the patient experiences various levels of risk of readmission or fatality. The results in this study account for the differences in the patient condition compared to when they were discharged from the primary healthcare centre. At the time of the discharge, the patient’s healthcare condition provided measurable information on the process of recovery or health deterioration. Since the participant involved in the study were not having any complications (only minor injuries) at the time of the discharge, their health outcomes varied significantly across different settings.

Demographics of the Participants

Participants had unique demographic characteristics that influenced the level of outcomes. The major demographic elements in this study were a race, age, gender, Medicaid, non-Medicaid. The result findings indicate outcomes from a pair for individuals with at least two distinct demographic variables. The total number of participants was 16, and their demographic characteristics are described below.

Competence of the Health Practioner

The health practitioners’ competencies were found to be a critical factor influencing the health outcomes of patients under transitional care. The clinicians’ competencies included cultural competences, scores on promoting patients’ transcendence, and experiences in transitional care. Healthcare practitioners played critical roles as case managers for the coordination of efforts with caregivers. Highly competent healthcare practitioners, especially in the communication and care coordination, yielded better recovery outcomes. In this study, there was no significant association between work experience and readmission risks for clinicians with high cultural competencies. Scores This study results show that cultural competencies are one of the unique characteristics that enhances positive outcomes in transitional care when all the other factors must be available. Although the clinicians had diverse demographic characteristics, basic cultural competencies on race, gender, and age had positive results in enhancing patients’ recovery. In this study, clinicians had low scores on the cultural competencies in Native Americans and Asian Americans yielding distinct results.

Contextual Factors/ Healthcare Environment

Participants in the environment with beautiful sceneries had significantly improved health outcomes by the end of the test period. Indeed, all patients were happy and made minimal complaints than in the contrasting condition. For those in an enclosed dark room, there was only negligible improvement in the health outcomes. Health outcomes improved for the young, male, and minority race only. Some of the patients from the pairs in the darkroom acquired additional minor injuries. The patient complained of uncontrollable changes in the temperature, increasing itching challenges.  Being, non-Hispanic white, above 65 years, female and non-Medicaid was an important factor in the adverse outcomes.

Participants in the rural areas also reported better outcomes in recovery. Indeed for all aspects of the environment majority of patients in the rural areas experienced quick recovery when all other factors were controlled. The urban environment was associated with increased cases of noise and sound pollution. These conditions were found critical in the adverse outcomes. The observation was critical in all demographic groups. The insurance coverage was used as a determinant factor for social class and the poverty conditions in the neighbourhood. The social class yielded significantly distinct outcomes on recovery.

Interaction of the Patient and Family

The social interactions with loved ones were shown to be critical factors influencing the recovery of patients under transitional care. This study shows that the patients who interacted with family and friends recovered faster than those in isolation. Age was a critical factor that influenced the outcomes of those above 65 years affected most by isolation. There were 2 cases of patients in isolation who reported deterioration with readmission risks should the condition persist for long. There was no gender and race variation in the patient health condition within the same study groups. The study shows that males and females had similar vulnerabilities in health deterioration across all racial groups. However, females’ participants experienced a slight improvement in the health outcomes when they interacted with the family.  The study did not show any variation in the impact of gender on participants’ health outcomes in isolation or otherwise.

Insurance coverage in this study explains the patient social class. The need for social interaction was significant across all study groups. All three patients with private premium insurance coverage experienced faster or slower recovery when in an interactive environment or isolation, respectively.  There was a slight variation in the results among patients without insurance coverage. These were the participant with the established use of community health centers as a source of healthcare services. Although those in isolation reported similar incidences of slower growth like those with insurance, the rate of recovery was not improved by increased social interactions. One of the key characteristics of Medicaid patients was age above 65 years, and outcomes were inclined to that particular age.

Care Coordination/ Information Sharing with the Caregiver

These results show that care coordination is a critical factor for recovery in patients under transitional care. Sharing information with the caregiver was found to improve recovery and to reduce adverse incidences. Two critical findings from the research were that sharing information with caregivers and the frequency of interaction directly influenced recovery. There was an improvement in the recovery for patients where there was a case manager coordinating healthcare services with caregivers and community centre. Information sharing emphasized on continuous evaluation and medication outcomes using tools like the REALM SF, In-hospital IHI risk stratification, and REALM R. Sharing information with the caregiver reduced the instances of medication errors and confusion. Caregivers had adequate mastery of important details concerning patient health status and medication. Participants, where there was no sharing of information with caregivers, reported slower recovery. There were significant variations in the health outcome across demographic characteristics. Care coordination proved to be important among the elderly patients when caregivers had no access to the internet. For some who had received training on caregiving and care coordination, there was a significant improvement in the health outcomes. The relationship was more critical among low-income families who had limited access to complementary healthcare services. For high-income household participant care coordination was significant in influencing recovery results, but the frequency was not a significant input.

Research Limitation

The case study design includes some limitations that affect the use of results in making transitional care coordination. However, the results provide an overview of important details regarding factors that affect the outcome for patients under transitional care.   The major limitation was the sample size for statistical analysis. This research question can best be answered through a quantitative design to measure the correlation between different variables. A sample of 20 was only adequate to provide qualitative information, and testing hypothesis could be important (Thorne, 2020).  This is significant since patients’ conditions are influenced by more than one factor. In other words, the qualitative results unreliable for making a clinical decision in this study (Ray, 2017). Increasing the sample size and measuring results through logistic regression analysis can improve the results (Ganapathy, 2016).

Learning experience

Through the completion of these four assignments and the whole learning process, I have managed to gain lots of new understandings. First, I have learned how to perform qualitative research based on case analyses and tools for assessing the health status of different patients.  Secondly, I have learned about patient printed care and how it can improve outcomes when the best methods are put in place such as the use of transitional nursing and care. Third, I have learned about APA formatting, especially through professor’s comments and feedback and library searches. Hence, I believe that the skills learned though these experiences will be of significance in my career development process.

Conclusions

This paper concludes that transitional nursing an important mode of treating older people with chronic illness. This care model of care helps improve outcomes and reduce the costs of care. Based on the results of this study, the conclusion is that transition nursing is an effective mode of caring for older patients as they move across different healthcare systems and clinicians. The aim is to improve outcomes, and reduce the cost of care along the process. It is a nurse-led, team-based mode of care that has been used across several geriatric care platform with positive outcomes. The TCM intervention focuses on improving care; enhancing patient and family caregiver outcomes; and reducing costs among vulnerable, chronically ill, older adults identified in health systems and community-based settings, such as patient-centred medical homes (PCMHs).

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