course materials

1. Healthcare: Nursing Challenges in Transitional Care Research
Healthcare: Nursing Challenges in Transitional Care Research ON Healthcare: Nursing
Challenges in Transitional Care ResearchFinal SubmissionStudents this project will allow
you to formulate and hypothetically develop your own research project. The purpose of this
project is for the student to complete all the different steps necessary to implement a
nursing research project. This project will be subdivided into 4 different papers that will be
submitted throughout the entire semester. The final paper will be the combination of the
four areas. Please see separate file items for each phase specific instructions. Again follow
APA style mandates.Paper will be submit it via turn it in.The final submission is basically the
combination of the other four phases into one paper. This paper will need to be corrected
with all of the feedback provided form previous papers. Include on this paper a conclusion
and learning experiences from the essentials and from the class.Essentials:• Essential I:
Background for Practice from Sciences and Humanities o Recognizes that the master’s-
prepared nurse integrates scientific findings from nursing, biopsychosocial fields, genetics,
public health, quality improvement, and organizational sciences for the continual
improvement of nursing care across diverse settings.• Essential II: Organizational and
Systems Leadership o Recognizes that organizational and systems leadership are critical to
the promotion of high quality and safe patient care. Leadership skills are needed that
emphasize ethical and critical decision making, effective working relationships, and a
systems-perspective.• Essential III: Quality Improvement and Safety o Recognizes that a
master’s-prepared nurse must be articulate in the methods, tools, performance measures,
and standards related to quality, as well as prepared to apply quality principles within an
organization. Healthcare: Nursing Challenges in Transitional Care Research• Essential IV:
Translating and Integrating Scholarship into Practice o Recognizes that the master’s-
prepared nurse applies research outcomes within the practice setting, resolves practice
problems, works as a change agent, and disseminates results.• Essential V: Informatics and
Healthcare Technologies 5 o Recognizes that the master’s-prepared nurse uses patient-care
technologies to deliver and enhance care and uses communication technologies to integrate
and coordinate care.• Essential VI: Health Policy and Advocacy o Recognizes that the
master’s-prepared nurse is able to intervene at the system level through the policy
development process and to employ advocacy strategies to influence health and health
care.• Essential VII: Interprofessional Collaboration for Improving Patient and Population
Health Outcomes o Recognizes that the master’s-prepared nurse, as a member and leader of
interprofessional teams, communicates, collaborates, and consults with other health

2. professionals to manage and coordinate care.• Essential VIII: Clinical Prevention and
Population Health for Improving Health o Recognizes that the master’s-prepared nurse
applies and integrates broad, organizational, client-centered, and culturally appropriate
concepts in the planning, delivery, management, and evaluation of evidence-based clinical
prevention and population care and services to individuals, families, and
aggregates/identified populations.• Essential IX: Master’s-Level Nursing Practice o
Recognizes that nursing practice, at the master’s level, is broadly defined as any form of
nursing intervention that influences healthcare outcomes for individuals, populations, or
systems. Master’s-level nursing graduates must have an advanced level of understanding of
nursing and relevant sciences as well as the ability to integrate this knowledge into practice.
. Nursing practice interventions include both direct and indirect care
components.a_phase_1__2.1.19.docdesign_phase_2_lit_review_with_literature__1_.docximple
mentation_phase_3.docxphase_4_research.docxUnformatted Attachment PreviewRunning
head: CHALLENGES IN TRANSITIONAL CARE Challenges in Transitional Care Frank
Calderon Florida National University Dr. Jorge Hirigoyen 2/1/2019 1 CHALLENGES IN
TRANSITIONAL CARE 2 Challenges in Transitional Care Introduction to the Problem The
case of failure in transitional care for the elderly and the chronically ill patients shows the
challenges in transitional care. Transitional nursing is the continuity of treatment of the
patients during the movement from one health center to another or home. The incidence
rehospitalization of people who have been released from the medical facilities to go home
for recovery is high. According to Ortiz research, in 2015, 35.6% of hospital readmission
within 30days of discharge is of elderly patients of age 75- 84. The authors indicate that this
is due to the patients worsening instead of getting better. Caregivers report that they do not
know how to handle the patients that are left in their care. Storm and Aase (2014) elaborate
that physicians say that elderly patients who have acute conditions are in vulnerable
positions of breakdown if the proper transition is absent. This is after evaluating that some
of the deaths reported of elderly patients in home-based and community- based care be
caused by poor. Ye and Quan (2016) point out that in 2012, China had the practice of the
medical practitioners discontinuing patient’s care once the patient is discharged. The
recovery care task was left with caregivers. This practice led to 30 percent of patient
declining in their well-being and regular functioning after been released from the hospital
especially the elderly. Healthcare: Nursing Challenges in Transitional Care ResearchIn the
homebased care, they lacked professional monitoring. In addition to the issue in the
transition of the elderly from the hospital to their home, the other failure is the transitional
care within the medical setting. Ortiz (2019) explains that the main case identified is
medication mix-up and CHALLENGES IN TRANSITIONAL CARE 3 error during the
movement of the patient emergency department to the intensive care unit. It also includes
the surgical unit setting. Problem Statement Lack of specialized nursing intervention is the
cause of the challenges in transitional care. It causes the readmission of elderly patients
with acute illness. The handoff of patients with no clear communication to the caregivers on
how to take of them cause mishandling of the patient (Morphet & Williams, 2014). Most
caregivers as well not trained on how to provide primary care to their patient. As a result,
they develop other conditions, or their case elevates and hence the need to go back to the

3. hospital. In some case, the patient may lack friends or family members to look after him or
her. In such a situation, the patient requires a transitional nurse to fulfill his/her medical
needs. The absence of one threatens the life and well-being of the patient. The difficulties of
transitional care within the medical setting are as a result of lack of specialized nurses who
are skilled and knowledgeable about providing professional care. Storm and Aase (2014)
illustrate that the issue of delay in the provision of therapy places the patient at risk. This is
a challenge that results because of unprofessional nurse handling the transfer of the patient
from unit to another. A specialized nurse is aware of the importance of timely and complete
communication. Poor transitional care in chronically ill people exists due to improper
coordination between the emergency department nurse and the one in the ICU. Ortiz (2019)
asserts that lack of organization confuses the right therapy for the patient which in turn
causes the delay in the recovery of the patient or the development of complications.
Furthermore, unlike a regular nurse, a specialized nurse provides quality transitional care.
They are experienced, well-trained and knowledgeable in giving transitional care. A
CHALLENGES IN TRANSITIONAL CARE 4 general nurse will administer primary care for an
ill person who is hospitalized. It is evident that the provision of transitional care by ordinary
medical practitioners is the cause of low-quality care. This creates patient and caregiver
dissatisfaction. The significance of the problem to Nursing The research problem is
significant to nursing. The problem is; lack of specialized nursing is the cause for the
challenges in transition care. Healthcare: Nursing Challenges in Transitional Care
ResearchIt directly concerns the nursing profession. It raises awareness of the weakness of
nursing in transitional care. It identifies that nursing service in transitional care is poor.
Patients are sent off without continuity care from professionals till they fully recover.
Moreover, the wrong care is given to the patients when they are moved within hospitals
from one setting to entity as nurses commonly provide the wrong medication. The problem
also informs the nurses their weakness in communication. It implies that unspecialized
nurse is not keen in providing timely and complete information to facilitate continuity care.
It mainly raises concerns in nurses in units where that transfer takes place. The problem as
well illuminates to nurses that poor professional coordination between them is resulting in
transitional care challenges since it hinders consultation and provision of information. It
similarly notifies the nurses their shortfall in performing specific crucial nursing roles. The
first one is ensuring the patient with no caregiver receives transitional care from them.
Secondly, it is educating the caregivers on how to handle the patients. In addition to
informing the nurses on the weak areas, it is enlightening them how to improve the nursing
job. It is asserted that specializing in transition care will enhance their task of providing
care to patients. Therefore, it is recommended that nurses who deal with transitional care
get additional education CHALLENGES IN TRANSITIONAL CARE 5 to gain skill. Finally, the
problem cautions the nurses on the impact of lack of knowledge and expertise. It shows that
the implications are detrimental to the patients whose health are already vulnerable.
Purpose of the Research The purpose of the research is to improve the quality of
transitional care. Healthcare: Nursing Challenges in Transitional Care ResearchThere is a lot
of research about the quality of the general health in the hospital. Therefore, various
stakeholders have invested in facilitating quality treatment. Nevertheless, the issue of

4. transitional care has not little study and as a result their no broad awareness of the matter
concerning transitional care, its challenges, and importance. This, in return, has led to little
attention from the government, physicians and donor, individuals who can contribute to
promoting good transitional care. This prompted my research on challenges in transitional
care to implore the health stakeholders to look into the issue and promote quality
transitional care. Furthermore, I considered research into the challenges of transitional care
would be a way to inform the nurses on the areas of their weakness and as a result,
encourage them to improve. It will eventually translate to quality transitional care. My
research exposes the challenges faced in transitional care and the problem which is lack of
specialized nurses. In addition to the nurses, it also creates awareness for the caregiver and
relevance of seeking help from transitional nurses. My study likewise enlightens the
medical trainers on the significance of including transitional care in the nursing curriculum.
Consequently, all nurses will have basic knowledge of rendering such care Finally, through
researching the subject on transitional care, I offer a platform for further research into the
area. Therefore, it will promote a better understanding of the issues facing transitional care.
This helps the stakeholders to see the severity of the issue and provide CHALLENGES IN
TRANSITIONAL CARE 6 assistance. Further research will likewise suggest better solutions
to address the problem facing transitional care. Research Questions What is the impact of
unspecialized nursing in transitional care? Why do unspecialized nurses promote low-
quality transitional care? What are the pros and cons of specialized nursing versus general
nursing? Master’s Essentials Alignment with My Topic Master’s essentials align with my
topic. It concurs with what my topic implies. Healthcare: Nursing Challenges in Transitional
Care ResearchThe second essential indicates that organizational and system leadership is
crucial in quality and safe patient care. My topic, on the other hand, illuminates on the
importance of leadership in patient care as some of the challenges like communication and
corporation are due to lack of leadership. Master’s essential III as well support the topic
problem which suggests that lack of specialized nurses is the cause of challenges. The
essential state that master-level nurses are aware that quality care goes hand in hand with
the methods and tools used. Similarly, the topic indicates that the use of unspecialized
nurses who have no master is the cause of the low-quality transitional care. Essential VII,
interprofessional collaboration asserts that masters prepared nurse is a leader and member
of the team who can communicate, cooperate and consult with other professionals.
Similarly, the topic agrees as it suggests that the challenges of lack of communication,
coordination, and consultation. It adds that this due to the use of unspecialized nurses
implying that nurses with maser can overcome the challenges. CHALLENGES IN
TRANSITIONAL CARE 7 The topic as well matches with essential IX. It is concerned with
master-level practice. It states that nurses with master’s level have scientific knowledge and
the capability to apply it into practice. My topic suggests that unspecialized nurses are not
as competent as the specialized ones who have a master’s degree. Therefore, they pose
challenges in transitional care which wouldn’t have been the case if specialized nurses
conducted the care. This essential as well claim that master’s prepared nurses can influence
positive healthcare result. The topic echoes that specialized nurses perform transitional
care better compared to general nurses. CHALLENGES IN TRANSITIONAL CARE 8

5. References Morphet, J., Griffiths, D. L., Innes, K., Crawford, K., Crow, S., & Williams, A. (2014).
Shortfalls in residents’ transfer documentation: Challenges for emergency department staff.
Australasian Emergency Nursing Journal, 17(3), 98-105. Ortiz, M. R. (2019). Transitional
Care: Nursing Knowledge and Policy Implications. Nursing Science Quarterly, 32(1), 73-77.
Storm, M., Siemsen, I. M., Laugaland, K., Dyrstad, D., & Aase, K. (2014). Quality in transitional
care of the elderly: Key challenges and relevant improvement measures. International
Journal of Integrated Care, 14(2). Ye, Z. J., Liu, M. L., Cai, R. Q., Zhong, M. X., Huang, H., Liang,
M. Z., & Quan, X. M. (2016). Development of the Transitional Care Model for nursing care in
Mainland China: a literature review. International journal of nursing sciences, 3(1), 113-
130. Running Head: DESIGN PHASE 2 1 Design Phase 2 Frank Calderon Florida National
University 2/27/2019 DESIGN PHASE 2 2 Design Phase 2 Methodology and Design of the
Study The study of transitions included the acute admissions of elderly individuals to the
hospitals up to the nursing homes of from the home to a home with a home-based care
services. Additionally, it included the discharge transitions of elderly from hospitals to a
nursing home or home also to home-based care services. Therefore, the methodology
included participant observation of admission and discharge transition process. This
involved an open-ended conversation with the patients and also with the patient’s next of
kin’s while involving the health care personnel (Design and Methodology of a Mixed
Methods Follow-up Study to the 2014 Ghana Demographic and Health Survey, 2017).
Healthcare: Nursing Challenges in Transitional Care ResearchThe observation also entails a
collection of data which is guided by a thematic guide which is adapted to the admission and
discharge transition in the health facilities. During the observation, the admission includes
observing the patient being handed over from the ambulance to the paramedics and
healthcare professionals in the emergency departments so that the patient can be observed
until he is handed over to the medical ward for further treatments. During this research, the
observation covers the data on interaction, coordination as well as dialogue between the
health practitioners and the patient. The observation ends when the researcher has a short
conversation with the patient and also with the healthcare personnel on the admission day
so as to help in clarification of some aspects pertaining to the current admission as well as
the entire process of admission. DESIGN PHASE 2 3 Additionally, the observation of
transitions of discharge commenced at the hospital ward on the expected day of discharge.
It involved the conversation between the researcher and the healthcare practitioner and the
person who is going to be discharged. The interaction also with the coordination and
dialogue taking place between the healthcare practitioner and the patient is observed. Such
a conversation is very helpful since it helps in understanding the discharge processes and
discharge transition. Short follow of up conversation also helps in understanding more the
processes and the bases of decisions made before a patient is discharged (Design and
Methodology of a Mixed Methods Follow-up Study to the 2014 Ghana Demographic and
Health Survey, 2017). Sampling Methodology The sampling method used in the research
was sampling which was utilized in the recruitment of the participants to take part in the
study. Additionally, the homecare offices in various municipalities of the country were
contacted and informed on the project and the need for the nursing leaders to participate in
interviews which will enable the researches to get the necessary information which will

6. also enhance their research. From these interviews, data is collected which also shed light
on the nursing leaders role and experience in the process of transition especially for the
older patients from the hospital to home. This implies that the interviews are conducted
only for data collection (Sahu & Singh, 2016). In essence, the semi-structured interview
guide dictated what the interviews should cover and how it should be carried out. It starts
with the general, discussion of transition processes and the patients experienced pertaining
to transitions received at homecare. The participants in this regards will focus on all the
experiences on the transition from the hospital to their homes, and DESIGN PHASE 2 4 then
researchers will decide on what next (Johnson, Pennell, Stoop, & Dorer, 2018). Healthcare:
Nursing Challenges in Transitional Care ResearchThe guide for the interview also entails
themes which include the organization of the internal and external cooperation, the
personal resources together with values which guide the quality of the care services.
Necessary tools Various technologies and tools are used in the research process. However,
the primary consideration if the health information technology tools which help to
smoothen the transition processes of the patients. It is worth noting that health IT involves
numerous technologies such as electronic health records. The electronic health records
entail saving of patient’s information electronically on computers which will enable
retrieving exercise to be very easy. Additionally, it includes clinical decision support which
also enables the health care personnel to make an effective decision which ensures that the
patients are handled very well and the decisions made helps them to regain their good
health. In essence, the health IT performs very significant tasks in various aspects of
transitions. It helps in capturing the information pertaining to the patient which helps in
informing the transition processes as well as the clinical history of the patients and what
needs to be done during the transition process. It is coherent that the design of the health IT
has the ability to support the transition process especially in supporting the individuals
who are involved in the transition processes (Riba, Parikh, & Greden, 2019). With the
information technology as well, the healthcare professionals will be able to connect to the
home care services where the elderly have been taken so that they can be taken care of until
they get well or improve on their health before they are being taken to their respective
homes. DESIGN PHASE 2 5 Any algorithms or flow maps created The various algorithms
created during the research include the Fourier transform which helps in enhancing the
senses of individuals. This is because the Fourier transform has been dubbed to be one of
the most significant algorithms in the healthcare sector. This transformation is a
mathematical technique which is used in breaking the complex signals which in turn will
enable the healthcare personnel to see the variation in their activities and what needs to be
attained. This helps in ensuring that they attain the objective of the organization. It is also
used in medical imaging which helps in creating date to check whether the patients who had
undergone imaging are fit to be discharged to be taken care of at homes. There is also a
Mumps algorithm which is a healthcare operating system which was developed in the
1960s but has been improved lately to reflect on the current needs of the patients and the
medical sector. Healthcare: Nursing Challenges in Transitional Care ResearchTherefore, it
can be denoted as a computer program which is used in the healthcare today to run
multiple programs and enable the healthcare personnel to understand the status of

7. numerous patients and decide on the next course of action. This operating system is
currently used in the powering of the entire hospital departments which helps in the
management of clinical records to enable the healthcare facilities to save a lot of time in
assessing the health care records for patients and improve the workplace efficiency (Morr &
AliHassan, 2019). Consequently, the probabilistic data matching is another algorithm which
enables numerous computer searches which are deterministic to be carried out. This is
because it carried DESIGN PHASE 2 6 out byte by byte comparison which can mainly be
used for typographical or data entry processes. Such probabilistic algorithms are depicted
to look for a various bit of information especially in the medical records while ranking them
according to the likelihood of the patients adopting very well to the medication and
estimate the time which the patient can remain within the hospital before they are
discharged to home care through a transition which will see them gain good health. This
probabilistic data help in retrieving of useful information which helps in research. Further,
the medical algorithms as well as aids for decision making which will help in promoting safe
healthcare as it also helps the healthcare personnel to enable them not to make mistakes
when carrying out their tasks. It is worth noting that with the increase in awareness of the
medical errors recently, it is also believed that the health professionals are using these
techniques into guiding them to offer quality care services and understand the patients and
those who need to go to various homecare homes when they need specialized care. A
medical algorithm in this regard can be a low tech as a lookup or a decision tree which helps
in carrying out complex decision making through the help of programming (Morr & Ali-
Hassan, 2019). Therefore, the medical algorithms remove some of the medical uncertainty
decision which in turn will help in improving the efficiency and most importantly the
accuracy of the teams provided. Notably, the health score which helps in quantifying illness
also is another algorithm which helps in evaluating the health status of the patients and
deciding whether they should be discharged to the