Case 23

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Phase One Paper

Jose Duarte

Florida National University

Nursing Research and Evidence-Based Practice

Instructor: Aciel Sagrera-Mulen

03/10/2024

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Transitional Nursing: A Critical Exploration of Patient Readmission Rates

The world of healthcare is an ever-changing one, fraught with new challenges around

every corner. Among the myriad of issues that have been getting increasingly more attention in

recent years, one of the most pressing is that of patient readmissions (Wong et al., 2018). The

specialist field of transitional nursing has emerged as one of the foremost tactics designed to

address this complex issue. By moving smoothly between different healthcare settings, these

nurses work to cut down on the likelihood that a patient will come back to a hospital while

supporting top patient outcomes. Nonetheless, this is no easy task. Many readmissions depend on

a variety of factors, from substandard discharge planning to the absence of effective

communication from one setting to the next (Kim & Kim, 2021).

Identifying the Problem

Patient readmissions, or the unplanned return of a patient to the hospital within a specific

period after being discharged, continue to challenge healthcare systems. They represent a

significant compromise in the safety and quality of care provided to patients, as well as an

important driver of the rising costs of care. In the United States, the average hospital readmission

rate is approximately 14.5%, varying from 11.2% to 22.3% across hospitals (CMS, 2023). This

dramatic statistic highlights the substantial financial implications of readmissions to a healthcare

delivery system that estimates billions of dollars are spent annually on readmissions.

Transitional nursing tackles the problem by assisting in this critical time to guarantee the

care they may require is communicated so they’re able to fulfill them right away, there is

continual communication, and they and their families receive complete support during the

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transition. Reducing the rate of readmissions as a consequence of subpar care coordination

during transitions can result in successful care transitions and better patient care.

Significance of the Problem to Nursing

Patient readmissions in healthcare institutions equate to much more than just finances;

they are a multi-dimensional issue that impacts various facets of patient care and nursing

practice. High rates of readmissions often indicate sub-optimal discharge planning, care

coordination, and patient education, and in the end, they not only compromise patient outcomes

but also place an additional strain on healthcare personnel and resources (Sili et al., 2023).

In addition, readmissions could negatively impact patient satisfaction and their

confidence in the healthcare system. Patients dealing with repeated readmissions may very well

be angry, frightened, and disheartened, factors that continue to impede their recovery. This issue

must be addressed, as it compromises not only patient outcomes and the quality of care but also

nurses' commitment to providing holistic, patient-centered care (Weiss et al., 2019).

Purpose of the Research

This study aims to explore the impact of transitional nursing in reducing patient

readmission rates. By examining the best practices, interventions, and strategies executed by

transitional nurses, this study will identify the most effective in reducing unplanned hospital

readmissions and enhancing care transitions.

Moreover, this study seeks to better understand the potential challenges and barriers that

suit a roadblock for a transitional nurse. By elucidating this information, this study can shed light

on current and pervasive obstacles and contribute to the expansion of practices that can target

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challenges that can provide more robust support to these nurses enabling them to offer better and

viable care for their patients.

Research Questions

1. What are the key factors contributing to patient readmissions, and how can transitional

nursing interventions address these factors?

2. What specific strategies and interventions have proven effective in reducing patient

readmission rates across different healthcare settings?

3. How can transitional nurses improve communication and collaboration among

healthcare providers, patients, and families to facilitate seamless care transitions?

4. What are the potential barriers and challenges faced by transitional nurses in their

efforts to reduce patient readmissions, and how can these be mitigated?

5. How can the findings of this research inform the development of evidence-based

guidelines and protocols for transitional nursing practice?

Master's Essentials Aligned with the Topic

This research topic aligns with several Master's Essentials, emphasizing the importance

of nursing leadership, evidence-based practice, and interprofessional collaboration in improving

patient outcomes and advancing the nursing profession (American Association of Colleges of

Nursing, 2017).

1. Essential I: Background for Practice from Sciences and Humanities

- Understanding the complex factors contributing to patient readmissions requires a

comprehensive understanding of various disciplines, including biology, psychology, and

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sociology. Transitional nurses must possess a deep understanding of the interplay between

physical, emotional, and social factors that influence patient outcomes during care transitions.

2. Essential II: Organizational and Systems Leadership

- Transitional nursing involves coordinating care across multiple settings, necessitating strong

organizational and systems leadership skills. Transitional nurses must navigate complex

healthcare systems, facilitate effective communication among various stakeholders, and advocate

for system-level changes to improve care transitions.

3. Essential III: Quality Improvement and Safety

Reducing patient readmissions is a key quality improvement initiative that directly impacts

patient safety and well-being. Transitional nurses contribute to increasing the overall quality of

care, and they promote patient safety throughout the continuum of care when they address

readmissions.

4. Essential IV: Translating and Integrating Scholarship into Practice

The purpose of this research is to change scholarly findings into evidence-based practices for

transitional nursing to improve patient care. Transitional nurses will be able to incorporate the

latest evidence-based interventions into their clinical practice to enhance care transition by

synthesizing the evidence on this topic.

5. Essential VII: Interprofessional Collaboration for Improving Patient and

Population Health Outcomes

Successful care transitions require seamless interprofessional collaboration among

healthcare providers, patients, and families. Essential to this process is the role of the transitional

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nurse, who fosters open communication, coordinating the patient's plan of care across the

healthcare continuum and ensuring that all stakeholders engage in the transition.

By aligning with these Master's Essentials, this research project underscores the

importance of transitional nursing in addressing the critical issue of patient readmissions and

fulfilling the nursing profession's commitment to deliver high-quality, patient-centered care.

Through a thorough explication of the challenges, strategies, and best practices in transitional

nursing, this study has the potential to yield important insights and make recommendations to

help inform future policy, protocols, and educational programs - ultimately enhancing patient

outcomes and the quality of care overall.

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References

American Association of Colleges of Nursing. (2017). The essentials of master’s education in

nursing. March 21, 2011.

https://www.aacnnursing.org/Portals/0/PDFs/Publications/MastersEssentials11.pdf

Centers for Medicare & Medicaid Services 2023 retrieved from:

https://www.definitivehc.com/resources/healthcare-insights/average-hospital-

readmission-state#:~:text=The%20average%20hospital%20readmission%20rate%20is

%2014.5%25.,to%2022.3%25%20in%20the%20U.S.

Kim, S. O. and Kim, J. (2021). Association of work environment and resilience with transition

shock in newly licensed nurses: a cross‐sectional study. Journal of Clinical Nursing,

30(7-8), 1037-1045. https://doi.org/10.1111/jocn.15649

Sili, A., Zaghini, F., Monaco, D., Molin, A., Mosca, N., Piredda, M., … & Fiorini, J. (2023).

Specialized nurse-led care of chronic wounds during hospitalization and after discharge:

a randomized controlled trial. Advances in Skin & Wound Care, 36(1), 24-29.

https://doi.org/10.1097/01.asw.0000897444.78712.fb

Weiss, M., Yakusheva, O., Bobay, K., Costa, L., Hughes, R., Nuccio, S., … & Bang, J. (2019).

Effect of implementing discharge readiness assessment in adult medical-surgical units on

30-day return to hospital. Jama Network Open, 2(1), e187387.

https://doi.org/10.1001/jamanetworkopen.2018.7387

Wong, J. S. W., Wincy, W. S., Cheng, M. T. C., Cheung, C. K., Cheung, T. Y. J., Lee, K. Y., …

& Yip, S. L. (2018). Challenges of fresh nursing graduates during their transition period.

Journal of Nursing Education and Practice, 8(6), 30.

https://doi.org/10.5430/jnep.v8n6p30

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