Case 28

1

Phase One Paper

Jose Duarte

Florida National University

Nursing Research and Evidence-Based Practice

Instructor: Aciel Sagrera-Mulen

03/10/2024

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 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 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 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 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.

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

2

Phase 2 Research Project Paper

Jose Duarte

Instructor: Aciel Sagrera-Mulen

Nursing Research and Evidence-Based Practice

Florida National University

03/24/2024

Methodology and Design for Evaluating the Impact of Transitional Nursing on Reducing Patient Readmissions

Brief Literature Review

Given the ever-growing issue of patient readmissions, the role of the transitional nursing care team becomes even more pressing as an effective solution. Various recent types of research have shown the efficiency of transitional nursing interventions and the list of barriers that prevent their implementation.

Transitional nursing interventions have come to be a cutting-edge approach to solving the severe problem of patient readmissions in diverse healthcare settings. Various researchers have demonstrated the profound effect of these interventions in decreasing unplanned hospital readmissions and improving the patients’ outcomes. One of the main components is the performance of organized discharge readiness assessments by nurses. These evaluations enable comprehensive discharge planning which in return reduces readmission rates and emergency visits (Weiss, et al., 2019).

Research studies have shown that comprehensive transitional care covering both pre-discharge and post-discharge provides valuable benefits to vulnerable populations of older medical patients (Rasmussen et al., 2021). These multidimensional interventions, implemented by nurses during the course of care transition, are essential safety valves for patients as they negotiate through challenging care transitions, preventing readmissions.

Enabling patients to manage their condition themselves represents the central objective of the patient-focused interventions which we should not ignore. Research demonstrates that nurse-led disease-specific self-care education has led to a decrease in both all-cause readmission and condition-specific readmission. In the systematic review and meta-analysis, Son et al (2020) particularly showed that heart failure self-care programs led by nurses accompanied a minimal decrease in readmission rates.

The vulnerable period immediately after discharge from acute care settings is quite critical for patients. Nurse-led bridging programs have demonstrated the highest efficiency in preventing rehospitalization of patients during the transitional period. Gilbert and colleagues in 2021 established the impact of a nurse-led transition bridging program and discovered a drastic drop in the readmissions of older patients within 30 days of discharge from an acute care unit.

Working together as a team is moreover a significant factor in implementing readmission rates decreasing regimens. Wood et al. (2019) report that patient readmission rates within 30 days of transferring from inpatient settings to outpatient settings are 57% lower when pharmacists are involved. The research demonstrates that the method for a timely care transition and the prevention of readmissions should not be mono but multi-disciplinary.

Proposed Methodology and Design

This study will combine qualitative and quantitative methods to obtain data covering all aspects of the effect of staff turnover on patient readmissions. In the quantitative part, we will use a cohort retrospective study. A qualitative one will comprise interviews with transitional nurses and focus groups with patients and their families.

The quantitative component will involve identifying two cohorts: patients who received transitional care and the other group who did not. Among the data collected from the patients' records will be readmission rates, and length of stay among other indicators of their conditions. Data will be analyzed using logistic regression and endurance analysis as statistical methods that assess the influence of transitional care nursing interventions on the readmission rate.

The investigation will consider possible confounding factors, like patient demographics (e.g., age, gender, socioeconomic status), comorbidities, and level of illness of the patient. We will apply propensity scoring to match patients with similar characteristics between the intervention and control groups. Through that, we will be sure that the observed readmission difference will be a consequence of transitional nursing interventions rather than other factors.

The qualitative part will comprise face-to-face interviews with the transition nurses to understand their views, experiences, and barriers to the implementation of interventions. The interviews will be conducted around the particular transitional nursing interventions, the roles and responsibilities of the transitional nurses, and the identified barriers and facilitators in their practice.

Along with this, the focus groups will be organized with patients and families who have received transitional nursing care to get the details of their experiences and views on care transitions. Topics like improved patient education and communication, enhanced support during transitions, and vulnerable areas in transitional care services will be explored in focus groups.

The qualitative data will be analyzed using thematic analysis through interviews and focus groups. The process of the data coding, recurring patterns, and themes identification and the interpretation of the findings will be systematic. Theme analysis will help in finding out the common themes and patterns concerning barriers, facilitators, and best practices in transitional nursing.

Sampling Methodology

A purposive sampling will be applied to select hospitals or healthcare systems with built-in transition nursing programs. This will involve targeting healthcare institutions that have already implemented transitional nursing interventions and have statistical data on patient readmission and outcomes. Patients who have been discharged from medical-surgical units within the last two years will be included in the study so that the sample size can be large enough for statistical analysis.

Propensity score matching will be done to have two groups, intervention, and control, with the same patient characteristics as age, comorbidities, and severity of the diseases. The matching process will make sure that the same factors affecting the outcome will be controlled for both the intervention and control groups at the beginning of the study.

As for our qualitative study, we will be using purposive sampling to choose transitional nurses with different levels of experience and from various healthcare settings. This will help us to get different views of transitional nursing experience and practice. This study shall apply the method of maximum variation sampling to include patients and families from a wide range of backgrounds, experiences, and transition scenarios. This sampling method is aimed at involving various points of view and experiences, which can include patients with different types of diseases, complexity levels, and social backgrounds. The studies may reveal such similarities and correlations that permeate all the participants irrespective of their differences.

Necessary Tools

EHR data extraction tools will be needed to extract patient data from the chosen hospitals or any healthcare systems, which will be used for the analysis. Information elements such as patient demographics, diagnoses, procedures, readmission dates, and other medical details will be extracted through these tools.

Software packages such as SPSS, R, or Stata will be core data analysis and modeling tools that will be employed in this research. These programs include various statistical methods such as logistic regression and survival analysis which are best for analyzing rates of readmission and other patient outcomes.

The qualitative data will be gathered by semi-structured interviews with transitional nurses who will be guided by the interview guides. The facilitators will write down the themes for the discussions and the questions they will ask, and will also maintain flexibility and provide scenarios where interviewees can answer the questions

Similarly, focus group guides will be generated to trigger dialog with patients and their families. The guides will consist of both direct questions and prompts which will stimulate more engagement of participants in transitional nursing care and care transitions.

Qualitative research software such as NVivo or MAXQDA will be applied for coding and thematic analysis of the interview and focus group data. The vast array of software tools offers efficient ways to organize, code, and analyze great volumes of qualitative data, therefore revealing repetitive themes and patterns.

Flow Map

Qualitative component

· Semi-structured interviews with transitional nurses

· Focus groups with patients and families

Retrospective cohort study:

· Identify intervention and control groups

· Extract patient data from electronic health records

· Perform propensity score matching

· Conduct statistical analyses

Quantitative component

Identify hospitals or healthcare systems with established transitional nursing programs.

Integrate the findings from the quantitative and qualitative components.

Use the integrated findings to develop evidence-based guidelines and protocols for transitional nursing practice.