EBP, IS, AND QI

Available online at www.sciencedirect.com

Nur s Out l oo k 6 8 ( 2 0 2 0 ) 5 0 4 �5 1 6 www.nursingoutlook.org

Amapping review of clinical nurse leader and nurse

*Co E-m

0029-6 https:

educator transitional care skills and competencies

Chimezie J. Agomoh, MSN, RN PhD (c)a,*, Maryellen D. Brisbois, PhD, RN, PHCNS-BCa,

Elizabeth Chin, PhD, MS, RN, ANP-Cb

aAssistant Professor, University of Massachusetts Dartmouth, College of Nursing, North Dartmouth, MA 02747 bAssistant Professor, Adult & Child Nursing, University of Massachusetts Dartmouth, College of Nursing, North Dartmouth, MA 02747

rresponding author: Chimezie J. Agom ail address: [email protected] (C 554/$ -see front matter � 2020 Elsevier //doi.org/10.1016/j.outlook.2020.02.003

A B S T R A C T

Background: Little is known about how nurses are prepared to participate or lead teams in conducting safe and effective care transitions, despite being a complex process in which the nurse has an integral role. Purpose: To conduct mapping review to identify and synthesize key recommendations regarding curriculum content needed to increase Clinical Nurse Leader and Nurse Educator student knowledge and skills regarding transitional care.Method: Guidelines for develop- ing the transitional care nurse role published by national accrediting bodies and certification organizations were reviewed to identify the required competencies. Findings: Components identified included: communication; teamwork and col- laboration; education and engagement of patient and family; promoting and support for self-management; and assessing/ managing risks/symptoms. Conclu- sion: Research evidence is needed to support academic preparation of nurses as leaders in care transition. The core transitional components identified can be used to develop competencies to assist training efforts of nurses in practice and educational settings. Cite this article: Agomoh, C.J., Brisbois, M.D., & Chin, E. (2020, July/August). A mapping review of clinical

nurse leader and nurse educator transitional care skills and competencies. Nurs Outlook, 68(4), 504�516.

https://doi.org/10.1016/j.outlook.2020.02.003.

A R T I C L E I N F O

Article history: Received 29 May 2019 Received in revised form 7 February 2020 Accepted 23 February 2020 Available online April 13, 2020.

Keywords:

Transitional care Clinical Nurse leader Nurse educator Competencies Nursing educational curriculum

oh, University of Massachusetts Dartmouth, North Dartmouth, MA 02747. .J. Agomoh). Inc. All rights reserved.

Introduction

Over the last decade, transitional care has emerged as an important area of health care delivery. Transitional care refers to “a broad range of time-limited services designed to ensure health care continuity, avoid pre- ventable negative outcomes among ‘at-risk pop- ulations,’ and promote the safe and timely transfer of clients from one level of care to another or from one type of setting to another” (Naylor, Aiken, Kurtzman, Olds & Hirschman, 2011, p. 747). This is a complex pro- cess in which the nurse has an integral role.

Since most adults prefer to reside in their homes (Barrett, 2015), health care delivery is increasingly extending beyond the acute care settings into the com- munity. In 2005, 165,276 nursing home residents expressed a preference to return to their community (Kitchener, Ng, Miller & Harrington, 2006). Over 63,000 nursing home residents who resided in an institution for at least 90 days were transitioned to home and community-based settings under the Centers for Medi- care and Medicaid Services’ Money Follows the Person program in 2015 (Irvin et al., 2017). Aging in the home is also associated with decreased cost (Kaye, Harring- ton & LaPlante, 2010). From 2004 to 2007, the average

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 505

monthly cost for community-based long-term care was $928 compared with $5,243 for nursing homes (Kaye et al., 2010). However, more than half of the individuals who

transitioned from nursing homes to community set- tings were hospitalized in the first year following tran- sition (Irvin et al., 2017). Emergency department visit rates ranged from 52% to 68% following transition from nursing homes to home within the first year (Irvin et al., 2017). Readmission and emergency room visits are attributed to inadequate discharge planning, poor communication between health care providers and gaps in follow-up care (Naylor, Hirschman, O’Connor, Barg, & Pauly, 2013). Previous research has identified a number of health and safety issues that arise during transitions in care from nursing homes to community settings including: inadequate preparation of client and informal caregiver for continuing care at home (Makaryus & Friedman, 2005; Pieper, et al., 2007); and, poor communication of vital information between health care providers (Boockvar et al., 2009). The use of transitional care nurses or coordinators in care transitions from hospitals to home has been asso- ciated with improved outcome, health-related quality of life, and reduced health care costs (Chiu & New- comer, 2007; Naylor et al., 2011; Toles, Col�on-Emeric, Naylor, Barroso, & Anderson, 2016). It is expected that using transitional care nurses in care transition from nursing homes to community settings will yield simi- lar results. Master’s prepared nurses play key roles in transi-

tional care. A clinical nurse leader (CNL), is defined as “a master’s educated nurse, prepared for practice across the continuum of care within any health care setting in today’s changing health care environment” (American Association of Colleges of Nursing [AACN], 2013, p.4), serves as a team manager in care coordina- tion and transitional care (AACN, 2013). CNL promote effective and timely communication among other health professional team to improve client care. They also provide education to clients, client groups, and ancillary health care professionals to ensure that cli- ents, families and communities are well informed regarding the transitional process and self-care man- agement (AACN, 2013). Nurse Educator (NE) defined as a master’s educated

nurse who applies “teaching/learning principles in work with clients and/or students across the contin- uum of care in a variety of settings” ((American Associ- ation of Colleges of Nursing 2011), p.6), provide education to clinical teams to develop skills needed to improve client care. NE promote professional develop- ment through implementation of educational activi- ties to meet identified learning needs of the team (NLN, 2005). With the implementation of the Affordable Care Act,

health care organizations are held accountable for the delivery of high-quality care (Burwell, 2015). A higher level of clinical reasoning is required of health care providers to meet the emerging demands of this

increasing complex health system. The Joint Commis- sion (2012) recommended that nursing schools and educational programs for other health care disciplines incorporate education describing care transition risk associated with care transition and factors that con- tribute to safe, effective care transition into their cur- riculum. NE need to have advanced knowledge of transitional care competences to adequately educate graduate and undergraduate nursing students on the skills required for effective coordination of care transi- tions. It is recommended that nurses have a conceptual

and practical foundation in the provision of transi- tional care as they assume expanded roles in the deliv- ery of transitional care (Naylor et al., 2011). However, little is known about how nurses are prepared to par- ticipate or lead teams in conducting safe and effective care transitions (Ellis, Meakim, Prieto & O’Connor, 2018). Master’s education prepares nurses as leaders and change agents in a complex health care delivery system that is moving in new directions for care deliv- ery to “elevate care in various roles and settings (American Association of Colleges of Nursing [AACN], 2011, p.3). Thus, a review of literature is needed to identify current curricular practice and gaps related to the academic preparation of NE as trainers and CNL as leaders in transitional care.

Purpose

The purpose of this mapping review was to identify and synthesize key recommendations regarding cur- riculum content needed to increase CNL and NE stu- dent knowledge and skills regarding transitional care. Guidelines for transitional care education developed by national accrediting bodies and certification organi- zations were reviewed to determine needed education and training that addresses the transitional care con- cepts and competencies. Research evidence about aca- demic preparation of CNL and NE in the skills and competencies needed for effective care transitions were also reviewed. This review provided evidence- based information regarding the extent to which the transitional care core competencies were represented in the current curriculum recommendations for NE and CNL programs as evidenced by AACN Essentials for Master’s Education in Nursing (2011) level essential competencies, CNL essential competencies, Certified Nurse Educator essential competencies, and the litera- ture on transitional care. It also identified educational gaps in programs of education and professional devel- opment required to adequately train CNL and NE on aspects of skills needed to support care transition. The central question guiding this review was: What core concepts and competencies should be in CNL and NE curriculums regarding transitional care? This question was expanded to two subquestions:

506 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

1. What knowledge and skills do NE and CNL need to educate and manage a transitional care team?

2. What transitional care competencies need to be added to programs of education and professional development to adequately train CNL and NE to educate and lead transitional care teams?

Background and Significance

In the United States (U.S.), the Affordable Care Act of 2010 supports innovative transitional care efforts to promote quality of care, improve client safety, and decreased health care cost (U.S. Center for Medicare and Medicaid Services [CMS], n.d.). The term transi- tional care sometimes gets confused with process of care coordination. Many articles tend to use the two concepts interchangeably; but there are fundamental differences between the two processes. Care coordina- tion is the deliberate organization of client care activi- ties and sharing of information among all of participants involved in a client’s care to facilitate safe care delivery (Agency for Health care Research and Quality [AHRQ], 2011). Transitional care is continuity of health care among at-risk populations as they move across levels of care and settings to another to avoid preventable, negative outcomes (Naylor & Sochalski, 2010). The American Nurses Association (ANA) identified

transitional care as a key component in its 2016 Cul- ture of Safety Campaign (America Nurses Association [ANA], 2016). The Institute of Medicine [IOM] (2010) rec- ommended incorporating transitional care competen- cies such as teamwork and collaboration into nursing educational curriculum (IOM, 2010). The ANA (2012) also recommended that transitional care be incorpo- rated into curricula across prelicensure and graduate nursing programs. Similarly, Benner et al. (2010) emphasized the need for nursing educators to broaden clinical experiences beyond the acute care setting to community-based agencies. Educating future nursing professionals in transitional care may better prepare nurses for this emerging role in health care delivery and subsequently ensure safe, effective care transition for improved outcomes.

Transitional Care Model

The Transitional Care Model (TCM) undergirded this review. The goal of the TCM is to promote an effective transition process that will improve care, reduce costs, and enhance positive outcomes for older adults in health systems and community-based settings (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). The TCM is a nurse-led, team-based model of care that uses a multidisciplinary approach to provide compre- hensive, holistic care to improve and enhance positive outcomes for older adults in health systems and com- munity-based settings (Hirschman et al., 2015).

The TCM framework consist of nine core compo- nents. These are (a) screening; (b) staffing; (c) main- taining relationships; (d) engaging clients and family caregivers; (e) assessing and managing risks and symptoms; (f) educating and promoting self-manage- ment; (g) collaborating; (h) promoting continuity; and, (i) fostering coordination (Hirschman et al., 2015). These core components are clearly defined and the framework is useful in understanding the process of transition. It has a broad scope and it is generalizable to different care situations and care settings. Studies have demonstrated that the use of the TCM is effective in reducing emergency room visits, hospital readmis- sions, and hospital costs related to care transition (Naylor et al., 1994; Naylor et al., 1999, Naylor et al., 2004, Naylor et al., 2011; Toles et al., 2016). In this model, the Advance Practice Registered Nurse

(APRN) works collaboratively with clients, their family caregivers, and other health teammembers in hospital discharge planning and home follow-up (Hirschman et al., 2015). Positive outcomes are achieved by teach- ing self-management and use of client-provider com- munication tools to individuals and their caregivers; early identification and response to potential problems to prevent decline in client health status; nurse home visit; and phone follow-ups (Hirschman et al., 2015). The role of the APRN in this model is similar to the role of a CNL in a practice setting and NE as a trainer needs to have knowledge of these competencies, thus the model is a good fit for CNL and NE. Collaboration with family and team members, client teaching and inter- disciplinary collaboration are also skills CNL need to possessed to manage care teams and NE need these skills to educate nurses in academic and clinical set- tings. Therefore, this model is appropriate for explor- ing the topic of transitional care for CNL and NE.

Methods

Design

A two-step approach was adopted for this review. First, the review method as outlined by Whittemore and Knafl (2005) was used to gather and synthesize the literature on current evidence about academic prepa- ration of graduate nursing students in the skills and competencies needed for effective care transitions. This method enhances rigor allowing the findings to inform evidence-based nursing practice and applica- tion to clinical practice. It allows for exploration of both empirical and theoretical literature on the topic of interest. Steps in the review include: (a) problem identification, (b) literature search, (c) data evaluation, and (d) data analysis (Whittemore & Knafl, 2005). The second step involved a website search of national accrediting bodies to identify education and skills rec- ommendations for transitional care role preparation and a website search of certification organizations to

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 507

identify essential competencies included in the aca- demic preparation of CNL and NE. As stated earlier, there is a need to look at academic preparation of CNL and NE to better understand current educational prac- tice and identify curriculum gaps in educating nurses to be leaders in transitional care for effective care tran- sitions.

Search Method

A literature search was conducted by using the follow- ing electronic databases: Cumulative Index to Nursing and Allied Health, PubMed, Education Resources Infor- mation Center, and MEDLINE. Literature published between 1994 and August 2018 was reviewed. Addi- tionally, the reference lists of selected articles (ances- try search) was scanned for relevant literature. Literature was reviewed from 1994 as that was when transitional care became popular topic for discussion in health care, and there is no mapping review addressing transitional care competencies for CNL and NE. Search terms used included ‘‘clinical nurse leader,” “nurse educator,’’ or ‘‘graduate nursing education,’’ in combination with “core competencies” or essential competencies,” AND “transitional care,” ‘‘handoff,’’ ‘‘discharge planning,’’ and/or ‘‘nursing”. Hand search- ing of the Journal of Nursing Education, Journal of Edu- cation and Research in Nursing, Journal of Clinical Nursing, Nurse Education Today, Journal of Continuing Education in Nursing, and the Journal of Nursing Man- agement was also conducted. In addition, websites were searched for guidelines

and recommendations on required competencies for transitional care nurses. Websites searched included: Agency for Health care Research and Quality, Ameri- can Association of Colleges of Nursing, Center for Medicare and Medicaid Services, Joint Commission Center for Transforming Health care Transitions of Care, The Joint Commission Division of Health Care Improvement, National League for Nursing, and World Health Organization. The following inclusion criteria were applied to the

literature search: (a) empirical and nonempirical liter- ature; (b) written in English language (c) published between 1994 and 2018; (d) focus on graduate nursing education (CNL and NE); (d) national guidelines that addressed knowledge and skills needed for transi- tional care; and (e) documents from certification organizations that addressed academic preparation of CNL and NE. Search findings were reviewed for rele- vance and studies were eligible for inclusion if they describe the incorporation of key transitional care con- cepts into graduate nursing education. Gray literature (conference proceedings and dissertations) was also reviewed for inclusion. Exclusion criteria included (a) studies that focused on undergraduate nursing stu- dent population; (b) studies that focused on clinical nurse specialist and advance practice nurses; (c) sys- tematic or literature review articles.

Search Results

The databases and websites search identified 67 articles pertinent to the topic of interest. Upon further screening, it was evident that none of the articles addressed the academic preparation of NE and CNL in the knowledge and skills needed to educate or manage a transitional care team. Subsequently, a search of organization websites was undertaken yielding 11 guidelines that addressed transitional care across set- ting. After screening 5 guidelines were eliminated because they did not meet the established inclusion criteria. Six guidelines from national accrediting bod- ies that addressed the nurses’ knowledge and skills required for effective transitional care were included in the review. A search of certification organizations websites for CNL and NE competencies yielded three documents outlining specific graduate nursing educa- tion competencies for these roles. These were also reviewed. The search strategy and results are depicted in Figure 1.

Appraisal of Evidence

Critical appraisal of the guidelines strength and quality of evidence was conducted following the criteria as described by the Johns Hopkins Nursing Evidence- Based Practice Model appraisal of nonresearch evi- dence (Newhouse, Dearholt, Poe, Pugh, & White, 2005). The strength of evidence was appraised along the six recommended measures: scope and purpose, stake- holder involvement, rigor of development, clarity and presentation, applicability, and editorial independence with each measure having five options (Level 1- Level V). The quality of evidence was also rated as recom- mended, and assigned a rating of High (A), Good (B), or Low/Major flaw (C) (Newhouse, et al., 2005). The strength of the evidence of all guidelines included in this review were rated level IV and the individual qual- ity of evidence was rated A and B. None of the articles were rated Low/Major flaw (C). Once the strength and the quality of evidence was assigned, then the strength of all evidence relating to each data rule was evaluated using the cumulative evidence rating scale developed by O’Neill, Dluhy, Fortier, & Michel, (2004) (Figure 2).

Cumulative Evidence Rating Scale

Analysis

A review matrix was created with a row for each guideline and columns for information extracted from each guideline. Information extracted included the author, year, title, website address and findings related to the review questions. Evidence strength, evidence

Database searched (CINAL, ERIC, MEDLINE, PubMed)

(n = 67 )

Websites searched (n = 14 )

Records a�er duplicates removed (n = 71 )

Records screened (n = 71)

Records excluded (n = 57)

Ar�cles did not answer review ques�ons

Guidelines assessed for eligibility (n = 14)

Guidelines excluded (n = 5)

Guidelines did not address knowledge and skills

needed for transi�onal care Guidelines included in

analysis (n = 9 )

Figure 1 –PRISMA flow diagram depicting search process (Moher et al., 2009).

508 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

quality, and cumulative evidence rating for each guideline were also included in the review matrix. Extracted data from guidelines for transitional care by national accrediting bodies were then compared against each other and common themes were extracted (Table 1). The AACN also developed scope and standards of

practice for the new role. This was followed by extrac- tion of relevant data from the AACN Essentials of

Figure 2 –Cumulative Evidence Ra

Master, Competencies and Curricular Expectations for CNL Education and Practice, and NLN Core Com- petencies of NE from certification organizations (Table 2). These competencies were reviewed for presence of

the five common competencies identified by the tran- sitional care guidelines. The common transitional care competencies extracted from literature were then compared to TCM nine core component (Table 3).

ting Scale (O’Neill et al., 2004).

Table 1 – Transitional Care Guidelines from National Accreditation Bodies

Author/Year Title Websites Findings Strength of Evidence

Quality of Evidence

Cumulative Evidence Rating

Dreyer, T (2014).

Care transitions: best practices and evidence- based programs (program ele- ments care tran- sition programs)

https://www.chrt. org/publication/ care-transi tions-best-practi ces-evidence- based- programs/

Multidisciplinary commu- nication,

Collaboration Coordination� Client/caregiver education Clinician involvement and shared accountability during all points of transi- tion

Comprehensive planning and risk assessment throughout hospital stay.

Standardized transition plans, procedures and forms

Standardized training Timely follow-up, support and coordination after the client leaves a care setting

Evaluation of transitions of care measures

IV B Marginal

Joint Com- mission (2012).

Transitions of care: the need for a more effec- tive approach to continuing cli- ent care (pro- gram elements care transition programs)

https://www.join tcommission. org/assets/1/18/ Hot_Topic s_Transition s_of_Care.pdf

Comprehensive discharge planning

Complete and timely com- munication of informa- tion

Medication reconciliation Client/caregiver education Open communication between providers.

Prompt follow-up visit with an outpatient provider after discharge.

IV A Marginal

Haas, et al., (2013).

AAACN nine core competencies

https://www. aaacn.org/sites/ default/files/ documents/Nur singEcArticle Jan_Feb2013_De velopingAmbula toryCare.pdf

Support for self-manage- ment

Education/engagement of clients and families

Cross setting communica- tion and transition

Nursing process including assessment, plan, imple- mentation/intervention, and evaluation

Teamwork and collabora- tion

Client-centered care plan- ning

Decision support and infor- mation systems

Advocacy Coaching/counseling of cli- ents and families

IV A Marginal

Hirschman, et al. (2015).

TCM core components

http://ojin.nursing world.org/Main MenuCatego ries/ANAMarket place/ANAPer iodicals/OJIN/ TableofCon tents/Vol-20- 2015/No3-Sept-

Screening Staffing, Maintaining relationship Engaging clients and Caregiver

Assessing/ Managing Risks and Symptoms

Educating/ Promoting Self- Management,

IV A Marginal

(continued)

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 509

Table 1 – (Continued)

Author/Year Title Websites Findings Strength of Evidence

Quality of Evidence

Cumulative Evidence Rating

2015/Continu ity-of-Care-Tran sitional-Care- Model.html

Collaborating, Promoting Continuity Fostering Coordination

Registered Nurses Association of Ontario [RNAO] (2014).

Care transitions: best practices guideline

https://rnao.ca/ sites/rnao-ca/ files/Care_Tran sitions_BPG.pdf

Communicating effec- tively;

Promoting client self-man- agement;

Reconciling medication Assessing client readiness and planning for transi- tions;

Collaborating with inter- professional teammem- bers and clarifying roles

IV A Marginal

“Transitions of care: The need for collabora- tion across entire care continu- um,” 2013.

Joint commission seven founda- tions to assure safe transitions

https://www.join tcommission. org/assets/1/6/ TOC_Hot_ Topics.pdf

Leadership support, Multidisciplinary collabo- ration,

Early identification of cli- ents/clients at risk,

Transitional planning, Medication management, Client and family action/ engagement,

Transfer of information.

IV A Marginal

510 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

Linkages

The guidelines for transitional care (education, prepara- tion) by national accrediting bodies were grouped and analyzed for content, and five common competencies were uncovered. These included communication, team- work and collaboration, education and engagement of client and family; promoting and support for self-man- agement; and assessing/ managing risks and symptoms (Appendix C). These competencies addressed knowl- edge and skills needed by CNL to lead team in transi- tional care interventions and NE to train and educate nurses. Other competencies that were discussed in the document that are not consistent across document include, medication reconciliation, leadership support and comprehensive discharge planning. These skills are part of undergraduate RN competencies.

Communication

Effective communication is necessary to ensure a seamless care transition and maintain continuity of care for individuals during the transition. Four of the guidelines identified communication as a requisite competency to train and lead team in transitional care (Dreyer, 2014; Haas, Ann Swan, & Haynes, 2013;

Hirschman, et al., 2015; “Transitions of care: The need for collaboration across entire care continuum,” 2013; RNAO, 2014). The CNL, as the team leader in transi- tional care, needs to ensure effective verbal and writ- ten communication among health care providers and interdisciplinary team members across care settings (Haas, et al., 2013). Dreyer (2014) also identified multi- disciplinary communication as key program element of effective care transition programs. Discharge pro- viders and agencies need to use a standardized tool to communicate pertinent information regarding the transitioning of individual to receiving agencies (Dreyer, 2014). All team members should be involved in sending and receiving information about the indi- vidual. Communication between providers across set- ting has to be timely and complete (Dreyer, 2014; Haas, et al., 2013; Joint Commission, 2012; RNAO, 2014). Each team member should address and respond to ques- tions promptly (Dreyer, 2014). CNL and NE competencies are designed to prepare

CNL and NE to develop the leadership and educational skills needed to lead and educate interprofessional teams (AACN, 2011). They are trained to communicate, collaborate, and consult with other health professio- nals. They should master effective communication strategies to develop, participate, and lead interprofes- sional teams and maintain effective working relation- ships with other health care professionals (AACN, 2011). Effective communication strategies are needed

Table 2 – CNL and NE Competencies

Author/Year Title Websites Findings

American Association of Colleges of Nurs- ing. (2011).

The essentials of master’s education in nursing Essential VII: Interprofes- sional Collaboration for Improving Client and Population Health Outcomes

http://www.aacn.nche.edu 1. Employ collaborative strategies in the design, coordination, and evaluation of client-centered care.

2. Use effective communication strate- gies to develop, participate, and lead interprofessional teams and partner- ships.

3. Mentor and coach new and experi- enced nurses and other members of the health care team.

4. Advocate for clients, families, care- givers, communities and members of the health care team.

5. Use leadership skills to teach, coach, and mentor other members of the health care team.

6. Functions as an effective group leader or member based on an in-depth under- standing of team dynamics and group processes

American Association of Colleges of Nurs- ing. (2013).

Competencies and curricu- lar expectations for clini- cal nurse leader education and practice.

http://www.aacn.nche. edu/cnl/CNL- Competencies

1. Providing clinical leadership for client- care practices and delivery

2. Participating in identification and col- lection of care outcomes

3. Accountability for evaluation and improvement of point-of-care out- comes

4. Risk anticipation andmitigation 5. Lateral integration of care for clients 6. Implementation of evidence-based practice

7. Team leadership, management and collaboration with other health care teammembers;

8. Use of information systems to improve health care outcomes

9. Resource stewardship 10. Advocacy for clients, communities, and the health professional team

American Association of Colleges of Nurs- ing. (2013).

CNL core competencies http://www.aacn.nche. edu/cnl/CNL- Competencie

1. Demonstrate professional and effective communication skills, including verbal, non-verbal, written, and virtual abilities

2. Assume a leadership role, in collabora- tion with other interprofessional team members, to facilitate transitions across care settings to support clients and families and reduce avoidable recidivism to improve care outcomes.

3. Provide leadership to the health care team to promote health, facilitate self- care management, optimize client engagement and prevent future decline including progression to higher levels

4. Demonstrate effective communication, collaboration, and interpersonal rela- tionships with members of the care delivery team across the continuum of care. of care and readmissions;

5. Assess actual and anticipated health risks to individuals and population

6. Demonstrate the ability to coach, dele- gate, and supervise health care team members in the performance of nursing procedures and processes with a focus on safety and competence.

(continued)

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 511

Table 2 – (Continued)

Author/Year Title Websites Findings

National League for Nursing. (2005).

NLN competency 5 - func- tion as a change agent and leader

http://www.wgec.org/ resources/art/nursing- core-competencies.pdf

1. Models cultural sensitivity when advo- cating for change,

2. Integrates a long-term, innovative, and creative perspective into the NE role,

3. Participates in interdisciplinary efforts to address health care and educational needs locally, regionally, nationally, or internationally,

4. Evaluates organizational effectiveness in nursing education

5. Implements strategies for organiza- tional change,

6. Provides leadership in the parent insti- tution as well as in the nursing program to enhance the visibility of nursing and its contributions to the academic com- munity,

7. Promotes innovative practices in edu- cational environments, and

8. Develops leadership skills to shape and implement change

CNL, clinical nurse leader; NE, nurse educator.

512 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

to facilitate timely, accurate dissemination of client information and prevent omissions of critical informa- tion during care transition.

Teamwork and Collaboration

Five guidelines identified collaboration as a key com- petency of transitional care (Dreyer, 2014; Haas, et al., 2013; Hirschman, et al., 2015; “Transitions of care: The need for collaboration across entire care continuum,” 2013; RNAO, 2014). Interprofessional collaboration is critical for improving client care outcomes. Multidisci- plinary collaboration is one of seven “foundations” identified by the “Transitions of care: The need for

Table 3 – Comparison Table between TCM Nine Core Component and Common Transitional Care Competencies Extracted from Literature

TCM Core Components Findings fromMapping Review

1. Screening 1. Communication, 2. Staffing 2. Teamwork and

collaboration 3. Maintaining relationship

3. Education and engage- ment of clients

4. Engaging clients and Caregivers

and family

5. Assessing/managing risks and symptoms

4. Promoting and support for self-management

6. Educating/ promoting self-management

5. Assessing/managing risks and symptoms.

7. Collaborating 8. Promoting continuity 9. Fostering coordination

collaboration across entire care continuum,” 2013 to assure safe transitions from one health care setting to another (p.8). CNL and NE involved in care transitions need to develop partnerships with the client, care- giver, and other health professional team members to improve client and population health outcomes. Col- laboration promotes consensus between the client and health professional team members on their plan of care (Hirschman, et al., 2015). The transitional care competencies required for successful collaboration include the ability to identify strategies to manage team member roles and accountability, resolve transi- tion conflicts to optimize the continuum of care, and assist team members to reprioritize activities accord- ing to the client’s immediate needs (Haas, et al., 2013).

Education and Engagement of Client and Family

Five guidelines identified education, engagement, coaching and counseling of clients and families as core competencies of transitional care (Dreyer, 2014; Haas, et al., 2013; Hirschman, et al., 2015; Joint Com- mission, 2012; “Transitions of care: The need for col- laboration across entire care continuum,” 2013). CNL and NE develop individualized education strategies with content that is age, education level, and culturally appropriate to coach and support the caregiver client to practice healthy behaviors (Haas, et al., 2013). They evaluate the client and caregiver’s health literacy, lan- guage proficiency cognitive abilities, readiness for learning and learning styles to tailor coaching toward their needs and goals. They assess leaner’s under- standing of content taught and re-evaluate and adjust the education plan as needed (AACN, 2013).

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 513

Educating, Promoting and Support for Self- Management

Educating clients on self-management strategies helps them to build confidence in their ability to care for themselves during/following care transition (RNAO, 2014). Four guidelines listed coaching and supporting clients on self-management as a core transitional care intervention (Haas, et al., 2013; Hirschman, et al., 2015; “Transitions of care: The need for collaboration across entire care continuum,” 2013; RNAO, 2014). Under- standing strategies for effective self-management pre- pares clients and family caregivers to monitor and manage their health conditions and identify and respond quickly to worsening symptoms (Hirschman, et al., 2015). CNL and NE need the knowledge and understanding of health promotion and disease pre- vention within chronic illness to assess clients’ under- standing of their chronic condition(s) and health maintenance.

Assessing/Managing Risks and Symptoms

Identifying individuals who are at risk during care tran- sition is an important role of the transitional care nurse (Hirschman, et al., 2015). They identify conditions that place clients at high risk and implement preventive measures to attenuate them. One of the fundamental aspects of a CNL’s practice is collecting and analyzing care outcomes (AACN 2013). CNL and NE also perform comprehensive needs (organizational) assessments for the purpose of improving staff skills or processes. Five guidelines identified assessment as key component of transitional care (Dreyer, 2014; Haas, et al., 2013; Hirsch- man, et al., 2015; “Transitions of care: The need for col- laboration across entire care continuum,” 2013; RNAO, 2014).

Comparing Guidelines from National Accrediting Bodies to Master’s Level Competencies

Five common themes that emerged from the compre- hensive review of the guidelines for transitional care from national accrediting bodies are communication, teamwork and collaboration, education and engage- ment of client and family; promoting and supporting self-management; and assessing/managing risks and symptoms. A review of the CNL and NE core compe- tencies for the presence of these five common compo- nents revealed that the five components are represented in the current curriculum for CNL and NE programs at the Master’s level. However, the compo- nents are broad in scope, and were not tailored specifi- cally to transitional care. A need exists for explicit transitional care education and leadership competen- cies for CNL and NE programs.

Discussion

The five core components that addressed the knowl- edge and competencies needed by CNL and NE to train and lead team in transitional care interventions were identified from the comprehensive review of the guidelines for transitional care from national accrediting bodies. The findings from this review are similar to four of the nine components of the TCM model (Appendix E). The four components include engaging individuals and their family caregivers; assessment; promoting self-management; and team- work and collaboration. Since studies that tested the effectiveness of the TCM model reported positive outcomes for individuals during care transitions, incorporating these components into CNL and NE program is necessary. Also, developing effective teaching strategies to teach the identified compo- nents is recommended. Ideally, NEs who teach CNLs to lead care transitions should have expertise in teaching care transitions. Based on the findings above, the TCM model is a good fit for use by all nurs- ing professionals and not only APRNs. The TCM model are represented in the current curriculum for CNL and NE programs at the Master’s level. Also, most of the components of the TCM models are skills already possess by registered nurses. TCM model is also considered appropriate in guiding research in the area of transitional care as its components are clearly defined and can be tested. A teaching strategy to improve teamwork and collab-

oration in CNL programs identified in literature is the TeamSTEPPS interactive workshops (Brock, et al., 2013). Simulation-based interprofessional TeamSTEPPS train- ing was found to be an effective education strategy to improve effective interprofessional team communica- tion (Brock, et al., 2013). Other approaches to teach interprofessional communication include workshops, online modules, and case studies (Foronda, MacWil- liams & McArthur, 2016). No research studies were found that specifically addressed the academic prepa- ration of CNL and NE in the skills and competencies needed for effective care transitions. A need exists for explicit graduate level transitional care competencies that will be incorporated into the graduate education preparation of the CNL and NE for training, managing and leading transitional care teams. Identifying transi- tional care educational competencies with focus on CNL and NE programs will be important step to take before planning specific trainings to educate registered nurses on transitional care. The Essentials of Master’s Education in Nursing pro-

vides specific curricular elements and a framework that equips nurses with higher level leadership skills to lead change, promote health and improve health outcomes (AACN, 2011). It is a guide used by graduate nursing programs to develop master’s in nursing edu- cation curricula in the U.S. It identifies the core knowl- edge and skills essential to all master’s prepared

514 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

nurses (AACN, 2011). Essential II, of The Essentials of Master’s Education in Nursing which is the organiza- tional and systems leadership prepares CNL and NE for leadership skills needed to initiate and maintain effective working relationships within interprofes- sional teams, learn skills include communication, col- laboration, mentoring and coaching, negotiation, delegation, and coordination (AACN, 2011). These skills are related to five core components identified in this review. Master level prepared nurses are able to coordinate comprehensive care for individuals, fami- lies, groups, across health care settings. The CNL competencies developed by AACN in

2013, build on the AACN The Essentials of Master’s Education in Nursing (2011) to reflect CNL practice within the changing health care environment (AACN, 2013). The nine AACN (2013) CNL competen- cies are similar to nine AACN (2011) Master’s Essen- tials. The CNL competencies were developed based on the ten fundamental aspects of practice. The CNL core competencies coincide with all the core components of transitional care identified by national accreditation bodies. The NLN established the NLN core competencies of

NE as the standards of practice for academic NE (NLN, 2005). These competencies provide a curricu- lum guide for master’s, nursing education programs (Halstead, 2007). Academic NE have the responsibil- ity of educating graduate nursing students to lead transitional care teams. NLN competency five, func- tion as a change agent and leader addressed a NE function as change agent and leader to create a pre- ferred future for nursing education and nursing prac- tice (NLN, 2005). This competency addressed some of the core components of the emerging role of transi- tional care nurse identified by national accreditation bodies. The five transitional care components identified in

this review can serve as a guide to develop a set of transitional care educational competencies to incorpo- rate into the academic preparation of CNL and NE as they prepare to position themselves in the roles of leaders and educators of transitional care teams. Research is needed to identify specific course con- cepts/content, evaluation of effectiveness of prepara- tion of CNL, NE to lead and educate teams for effective client outcomes.

Limitations

The lack of empiric evidence to support the academic preparation needs of CNL and NE weakened the results of this review. Due to a lack of evidence, the author was unable to comprehensively understand the devel- opment of transition care competencies for CNL regarding preparing to lead transitional care teams or NE as trainers. Grant funding could be made available from nursing societies and other organizations con- cerned with improving health care quality so that this research gap can be addressed.

Recommendations

Based on the findings of this review, the author offers the following recommendations

� Content such as skills necessary to promote commu- nication, teamwork and collaboration, education and engagement of client and family; promoting and support for self-management; and assessing/ man- aging risks and symptoms should be included in the graduate nurse education of CNL to prepare them for practice leadership and education in the practice environment.

� Nurse curricula need to develop effective teaching strategies to teach transitional care skills in graduate nurse education programs for CNL and NE

� Nurse researchers need to identify a set of transi- tional care educational competencies for graduate nurse education programs for NE as professional development, nursing education and practice set- tings need developed competencies to address atti- tudes, knowledge, and skills of nurses involved in transitional care.

� NE need to provide CNL students opportunities to practice skills for managing care transition.

Conclusion

Based on IOM and ANA mandate to develop workforce for the future- emerging role of transitional care nurse, research evidence is needed to support academic prep- aration of CNL as leaders and NE as educators in the emerging role of care transition nurse. Nurses in pro- fessional development, nursing education and practice settings need to develop the needed competencies to address attitudes, knowledge, and skills of nurses regarding transitional care. To support NE in profes- sional development, the core components identified in this review can be used to develop competencies to assist training efforts of nurses in practice and educa- tional settings.

Supplementary materials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.out look.2020.02.003.

R E F E R E N C E S

Agency for Healthcare Research and Quality (2011). Care coordination. Retrieved from https://www.ahrq.gov/

Nur s Ou t l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6 515

professionals/prevention-chronic-care/improve/coordi nation/index.html

American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Retrieved from http://www.aacn.nche.edu

American Association of Colleges of Nursing. (2013). Com- petencies and curricular expectations for clinical nurse leader education and practice. Retrieved from http:// www.aacn.nche.edu/cnl/CNL-Competencies

American Nurses Association (2016) Culture of safety: Partnering to promote safety in the nursing profession. Retrieved from http://www.theamericannurse.org/ 2016/06/02/celebrate-national-nurses-week-2016/

Barrett, L. (2015). Home and Community Preferences of the 45+ Population. Washington DC: AARP Research Center. Retrieved from https://doi.org/10.26419/res.00105.001.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Edu- cating nurses: A call for radical transformation. San Fran- cisco, CA: Jossey-Bass.

Boockvar, K. S., Liu, S., Goldstein, N., Nebeker, J., Siu, A., & Fried, T. (2009). Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual- ity and Safety in Health Care, 18(1), 32–36, doi:10.1136/ qshc.2007.025957.

Brock, D., Abu-Rish, E., Chiu, C., Hammer, D., Wilson, S., Vorvick, L., & Zierler, B (2013). Republished: Interpro- fessional education in team communication: Working together to improve patient safety. Postgraduate Medical Journal, 89(1057), 642–651, doi:10.1136/postgradmedj- 2012-000952rep.

Burwell, S. M. (2015). Setting value-based payment goals�HHS efforts to improve U.S. health care. New England Journal of Medicine, 372(10), 897–899, doi:10.1056/ NEJMp1500445.

Chiu, W. K., & Newcomer, R. (2007). A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly. Profes- sional Case Management, 12(6), 330–336, doi:10.1097/01. PCAMA.0000300406.15572.e2 quiz 337-338.

Dreyer, T. (2014). Care transitions: best practices and evi- dence-based programs. Home Healthcare Nurse, 32(5), 309–316. Retrieved from https://www.chrt.org/publica tion/care-transitions-best-practices-evidence-based- programs/.

Ellis, D. M., Meakim, C., Prieto, P., & O’Connor, M. (2018). Transitional care experience in home health: Exposing students to care transitions through scenarios and simulation. Nursing Education Perspectives, 39(1), 48–50, doi:10.1097/01.NEP.0000000000000148.

Foronda, C., MacWilliams, B., & McArthur, E. (2016). Inter- professional communication in healthcare: An integra- tive review. Nurse Education in Practice, 19, 36–40, doi:10.1016/j.nepr.2016.04.005.

Haas, S., Ann Swan, B, & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nursing Economic$, 31(1) 44-43.

Halstead, J. A. (Ed.). (2007). Nurse educator competencies: Cre- ating an evidence-based practice for nurse educatorsNew York, NY: National League for Nursing.

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transi- tional care model. Online Journal of Issues in Nursing, 20 (3), doi:10.3912/OJIN.Vol20No03Man01 1-1.

Institute of Medicine. (2010). The future of nursing: Focus on education report brief. Washington, DC: National Acade- mies Press. Retrieved from http://www.nationalacade mies.org/hmd/~/media/Files/Report%20Files/2010/

The-Future-of-Nursing/Nur sing%20Education%202010%20Brief.pdf.

Irvin, C. V., Bohl, A., Stewart, K., Williams, S. R., Steiner, Al, Denny-Brown, N., et al. (2017).Money follows the person 2015 annual evaluation report. Cambridge, MA: Mathematica Policy Research. retrieved from https:// www.medicaid.gov/medicaid/ltss/downloads/money- follows-the-person/mfp-2015-annual-report.pdf.

Joint Commission (2012). The need for a more effective approach to continuing patient care. Hot topic in health care, 1, 1–7. Retrieved from https://www.jointcommis sion.org/assets/1/18/Hot_Topics_Transitions_of_Care. pdf.

Kaye, H. S., Harrington, C., & LaPlante, M. P. (2010). Long- term care: Who gets it, who provides it, who pays, and howmuch? [corrected] [published erratum appears in HEALTH AFF 2010 mar; 29(3):567]. Health Affairs, 29(1), 11–21, doi:10.1377/hlthaff.2009.0535.

Kitchener, M., Ng, T., Miller, N., & Harrington, C. (2006). Institutional and community-based long-term care: A comparative estimate of public costs. Journal of Health & Social Policy, 22(2), 31–50, doi:10.1300/J045v22n02_03.

Makaryus, A. N., & Friedman, E. A. (2005). Patients’ under- standing of their treatment plans and diagnosis at dis- charge.Mayo Clinic Proceedings, 80(8), 991–994.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Annals of Internal Medicine, 151, p. 287.

Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine, 120(12), 999–1006.

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., et al. (1999). Comprehensive discharge planning and home follow-up of hospital- ized elders: A randomized clinical trial. JAMA, 281(7), 613–620 joc80991.

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675–684, doi:10.1111/j.1532- 5415.2004.52202.xJGS52202.

Naylor, M. D., & Sochalski, J. A. (2010). Scaling up: Bringing the transitional care model into the mainstream. Issue Brief (The Commonwealth Fund), 103, 1–12.

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746–754, doi:10.1377/hlthaff.2011.0041.

Naylor, M. D., Hirschman, K. B., O’Connor, M., Barg, R., & Pauly, M. V. (2013). Engaging older adults in their tran- sitional care: What more needs to be done? Journal of Comparative Effectiveness Research, 2(5), 457–468.

National League for Nursing. (2005). Core competencies of nurse educators with task statements Retrieved from http://www.wgec.org/resources/art/nursing-core-com petencies.pdf

Newhouse, R., Dearholt, S., Poe, S., Pugh, L. C., White, K. (2005). The Johns Hopkins Nursing Evidence-based Prac- tice Rating Scale. Baltimore, MD, The Johns Hopkins Hospital; Johns Hopkins University School of Nursing.

O’Neill, E. S., Dluhy, N. M., Fortier, P. J., & Michel, H. E. (2004). Knowledge acquisition, synthesis, and valida- tion: A model for decision support systems. Journal of Advanced Nursing, 47, 134–142, doi:10.1111/j.1365- 2648.2004.03072.x.

516 Nur s Out l o o k 6 8 ( 2 0 2 0 ) 5 0 4�5 1 6

Pieper, B., Sieggreen, M., Nordstrom, C. K., Freeland, B., Kulwicki, P., Frattaroli, M., et al. (2007). Discharge knowledge and concerns of patients going home with a wound. Journal of Wound, Ostomy, and Continence Nurs- ing, 34(3), 245–253, doi:10.1097/01. WON.0000270817.06942.00 quiz 254-245.

Registered Nurses Association of Ontario. (2014). Care transitions best practice guidelines. Retrieved from http://rnao.ca/sites/rnao-ca/files/Care_Transi tions_BPG.pdf.

Toles, M., Col�on-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. (2016). Transitional care in skilled nursing facilities: A multiple case study. BMC Health Services Research, 16, 1–14, doi:10.1186/s12913-016- 1427-1.

U.S. Center for Medicare and Medicaid Services (n.d.) Affordable care act (ACA) https://www.healthcare.gov/ glossary/affordable-care-act/

Joint Commission. (2013). Transitions of care: The need for collaboration across entire care continuum. Hot topics in health care, 2, 1–8. Retrieved from https://www. jointcommission.org/assets/1/6/TOC_Hot_Topics.pdf.

Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52 (5) 546Y553.

American Nurses Association (2012). The value of nursing care coordination a white paper of the American nurses association. Retrieved from https://www.nur singworld.org/~4afc0d/globalassets/practiceandpolicy/ health-policy/care-coordination-white-paper-3.pdf