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butterflyl
2 years ago
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files (2)AACNEssentialPaper.docx
Phase1-Planning.edited.docx
AACNEssentialPaper.docx
Library Assignment: AACN Essential Paper
This assignment provides a concise description and appraisal of the American Association of Colleges of Nursing (AACN) Essentials of master’s Education in Nursing. Following APA guideline, briefly explain each essential reflecting on each essential affects the clinical practice and the author's interpretation of each essential.
Include a (Title page, abstract, introduction, body, conclusion, and reference page). Use each of the subheadings in your paper- for example: Abstract, the problem, review of literature, etc.
Please submit it via Turnitin by the end of Week 1. This assignment is 10 points.
It would be a good idea to select a study that you would like to replicate hypothetically for your research assignments. Once you select a research study- utilize the rubric below to answer questions based on the article you have selected.
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Criteria |
Points |
Total Score |
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Title Page: Title of article, journal information, and your name and date |
10 point |
Your score
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Abstract: Summary of an article (1-2 paragraphs) |
10 point |
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The Problem: (2 or 3 paragraphs) Is the problem clearly stated? Is the problem practically important? What is the purpose of the study? What is the hypothesis? Are the key terms defined? |
10 point |
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Review of Literature: (1 -2 paragraphs) Are the cited sources pertinent to the study? Is the review too broad or too narrow? Are the references recent? Is there any evidence of bias? |
20 points |
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Design and Procedures: (3-4 paragraphs) What research methodology was used? Was it a replica study or an original study? What measurement tools were used? How were the procedures structures? Was a pilot study conducted? What are the variables? How was sampling performed? |
20 points |
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Data analysis and Presentation: (1 - 2 paragraphs) |
20 points |
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How was the data analyzed? Did findings support the hypothesis and purpose? Were the weaknesses and problems discussed? |
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Conclusions and Implications: (2-3 paragraphs) |
10 point |
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Are the conclusions of the study related to the original purpose? Were the implications discussed? Whom will the results and conclusions affect? What recommendations were made at the conclusion? What is your overall assessment of the study and the article? |
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Total |
100 points (100%) |
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Grade |
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Phase1-Planning.edited.docx
2
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days Among Patients with Chronic Heart Failure
Antonio Estremera
FNU
Nursing Research and Evidence-Based Practice
Professor: Dr. Carmen Lazo
November 9, 2024
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days Among Patients with Chronic Heart Failure
Chronic diseases are among the leading causes of hospitalization, death, and economic burden globally. Chronic diseases cause 73% of all deaths and 60% of the global disease burden, respectively. One of the major problems in chronic disease management is the frequent readmission of patients to hospitals; this is partly because transitional care is very fragmented. More than 50% of patients with chronic diseases are readmitted to hospitals within 30 days following discharge (Joo & Liu, 2021). Heart failure is among the major chronic diseases. It is a prevalent condition affecting more than 6.7 million people aged 20 years and above in the United States (CDC, 2024). Transitional care of patients with chronic conditions such as CHF is an important element in health care, as it appraises continuity and safety as the patients undergo different transitions from one care setting to another. Given the above figures, transitional care interventions are crucial in reducing readmission rates to improve patient outcomes and decrease overall healthcare system burdens. This paper discusses transitional care's role in managing CHF patients post-discharge to minimize early hospital readmissions, drawing on prior nursing research to emphasize its importance.
Identification of the Problem
Hospital readmission in the first 30 days after being discharged is a recurring problem in healthcare, especially with patients diagnosed with chronic heart failure. These readmissions may indicate potential gaps in discharge planning, patient education, and support in the post-discharge periods, which are integral to transitional care (Ayenew et al., 2023). The majority of patients with CHF are not engaged in illness self-management because of complex medical regimens, diet restrictions or continuous monitoring. According to Becker et al. (2021), these readmissions for admission happen due to failure in communication, follow-up services, and support of such patients any time they go to their homes from the hospital. This issue is linked to patient morbidity and mortality and healthcare system expenditures. Managing these factors may improve post-discharge transitional care measures to improve patient stability and reduce readmission rates in these populations (Rammohan et al., 2023).
Significance of the Problem to Nursing
This issue of readmission among CHF patients is highly significant in the nursing field, especially in transitional and community-based settings. Nurses are central in discharge planning, patient education, and coordinating care to support the patient through the transitional period. Continuation of care is one of the major responsibilities of nursing professionals, something quite relevant to these patients, who require detailed guidance in managing their condition successfully at home (Karam et al., 2021). Nurses can help promote improved compliance with treatment regimens, reduced medication errors, and increased patient-family empowerment to engage in self-care through implementing and refining transitional care strategies. The roles promote patient outcomes and support healthcare goals of quality of life and preventable hospital readmissions. Transitional care, therefore, allows nurses to apply advanced skills in the coordination of care, patient advocacy, and working collaboratively with other professionals from other disciplines.
Purpose of the Research
This study aims to identify gaps in the current transitional care interventions and compare the 30-day readmission rate for patients with chronic heart failure. This research will further refine the understanding of which aspects of transitional care, including follow-up visits, patient education, and home health monitoring, are the most valuable for avoiding early readmissions. The research also aims to investigate how tailored transitional care plans can be adapted to meet patients' individual needs, recognizing that CHF patients vary in severity, comorbid conditions, and social support. The ultimate goal of this study is to provide evidence-based recommendations for healthcare providers, particularly nurses, on best practices for managing CHF patients post-discharge to improve outcomes and reduce readmissions.
Research Questions
1. What specific components of transitional care are most effective in reducing 30-day readmission rates for patients with chronic heart failure?
2. How does patient education and self-management support during the transition period impact readmission rates in this population?
3. How can individualized care plans enhance the effectiveness of transitional care for patients with CHF?
4. What role do follow-up interventions, such as home visits or telehealth, play in supporting CHF patients post-discharge?
Master's Essentials Aligned with the Topic
Essential I: Background for Practice from Sciences and Humanities
This essential underscores the need for nursing practice based on a wide knowledge of sciences and humanities. During the care of patients with CHF, nurses will draw knowledge from physiology, pharmacology, and patient psychology to develop comprehensive transitional care plans addressing both physical and mental health. By integrating these multifaceted arenas of cognition, nurses will be better equipped to develop holistic and personalized plans of care that meet the complex needs of CHF patients during their transition from hospital to home.
Essential II: Organizational and Systems Leadership
This essential highlights the need for a higher level of professional nursing leadership competencies to maneuver and coordinate healthcare systems environment solutions efficiently. In particular, when discharging CHF patients, nurses need to involve other departments, support the need for resources, and invest in structured transition plans to provide the appropriate care continuity. Strong organizational and systems leadership allows nurses to reduce readmissions through systemic improvements, demonstrating its impact on patient outcomes.
Essential III: Quality Improvement and Safety
This essential emphasizes utilizing improvement and quality management concepts to boost the efficiency of patient safety as well as treatment. Nurses who work with CHF patients diagnose the factors that cause readmission and implement knowledge-based changes in the transitional care processes of the patients. Nurses play an important role in making discharge plans safer and less risky, meaning they try to reduce the factors that can lead to readmission of heart failure patients by paying a lot of attention to the safety of patients any time they are being discharged or followed up.
Essential IV: Translating and Integrating Scholarship into Practice
This essential emphasizes the need for applied research conducted to enhance patient care through the new implementation of practical nursing practices (Giddens et al., 2022). Transitional care and readmission control are evidence-based practices. Hospital nurses use research to handle CHF patients and apply effective solutions. They ensure the research findings are implemented within practice, promoting patient care, especially for the most vulnerable.
Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes
This essential stresses the need to collaborate with an interactive and multifaceted team in planning and providing client care that enhances pen-patient status. Transitional care for CHF patients generally requires teamwork between nurses, physicians, pharmacists, social workers, and home health aides to provide all health needs. This collaboration guarantees that CHF patients get holistic and comprehensive care at each stage of their cycle, hence minimizing NICU readmission rates.
Essential VIII: Clinical Prevention and Population Health for Improving Health
This essential calls for integrating preventive care and population health, increasing well-being, and decreasing the number of disease incidents (Giddens et al., 2022). Transitional care for CHF patients relates to and supports this goal by addressing the condition and averting readmission by following up and educating patients on the necessary care. Nurses can use the interventions to enhance the well-being of CHF patients and contribute to healthcare policies that reduce the demands on health facilities.
References
Ayenew, B., Kumar, P., Hussein, A. A., Gashaw, Y., Girma, M., Ayalew, A., & Tadesse, B. (2023). Heart failure drug classes and 30-day unplanned hospital readmission among patients with heart failure in Ethiopia. Journal of Pharmaceutical Health Care and Sciences, 9(1). https://doi.org/10.1186/s40780-023-00320-y
Becker, C., Zumbrunn, S., Beck, K., Vincent, A., Loretz, N., Müller, J., Amacher, S. A., Schaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at Hospital Discharge and Rates of Readmission. JAMA Network Open, 4(8). https://doi.org/10.1001/jamanetworkopen.2021.19346
CDC. (2024). Cardiovascular diseases (CVDs). Who. int. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases
Giddens, J., Douglas, J. P., & Conroy, S. (2022). The Revised AACN Essentials: implications for nursing regulation. Journal of Nursing Regulation, 12(4), 16–22. https://doi.org/10.1016/s2155-8256(22)00009-6
Joo , J. Y., & Liu , M. F. (2021). Effectiveness of transitional care interventions for chronic illnesses: A systematic review of reviews. Applied Nursing Research, 61, 151485. https://doi.org/10.1016/j.apnr.2021.151485
Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: a scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518
Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S., Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing care transition teams to mitigate hospital readmissions and improve patient outcomes. Cureus, 15(5). https://doi.org/10.7759/cureus.39022
