Phase One Paper
Jose Duarte
Florida National University
Nursing Research and Evidence-Based Practice
Instructor: Aciel Sagrera-Mulen
03/10/2024
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Transitional Nursing: A Critical Exploration of Patient Readmission Rates
The world of healthcare is an ever-changing one, fraught with new challenges around
every corner. Among the myriad of issues that have been getting increasingly more attention in
recent years, one of the most pressing is that of patient readmissions (Wong et al., 2018). The
specialist field of transitional nursing has emerged as one of the foremost tactics designed to
address this complex issue. By moving smoothly between different healthcare settings, these
nurses work to cut down on the likelihood that a patient will come back to a hospital while
supporting top patient outcomes. Nonetheless, this is no easy task. Many readmissions depend on
a variety of factors, from substandard discharge planning to the absence of effective
communication from one setting to the next (Kim & Kim, 2021).
Identifying the Problem
Patient readmissions, or the unplanned return of a patient to the hospital within a specific
period after being discharged, continue to challenge healthcare systems. They represent a
significant compromise in the safety and quality of care provided to patients, as well as an
important driver of the rising costs of care. In the United States, the average hospital readmission
rate is approximately 14.5%, varying from 11.2% to 22.3% across hospitals (CMS, 2023). This
dramatic statistic highlights the substantial financial implications of readmissions to a healthcare
delivery system that estimates billions of dollars are spent annually on readmissions.
Transitional nursing tackles the problem by assisting in this critical time to guarantee the
care they may require is communicated so they’re able to fulfill them right away, there is
continual communication, and they and their families receive complete support during the
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transition. Reducing the rate of readmissions as a consequence of subpar care coordination
during transitions can result in successful care transitions and better patient care.
Significance of the Problem to Nursing
Patient readmissions in healthcare institutions equate to much more than just finances;
they are a multi-dimensional issue that impacts various facets of patient care and nursing
practice. High rates of readmissions often indicate sub-optimal discharge planning, care
coordination, and patient education, and in the end, they not only compromise patient outcomes
but also place an additional strain on healthcare personnel and resources (Sili et al., 2023).
In addition, readmissions could negatively impact patient satisfaction and their
confidence in the healthcare system. Patients dealing with repeated readmissions may very well
be angry, frightened, and disheartened, factors that continue to impede their recovery. This issue
must be addressed, as it compromises not only patient outcomes and the quality of care but also
nurses’ commitment to providing holistic, patient-centered care (Weiss et al., 2019).
Purpose of the Research
This study aims to explore the impact of transitional nursing in reducing patient
readmission rates. By examining the best practices, interventions, and strategies executed by
transitional nurses, this study will identify the most effective in reducing unplanned hospital
readmissions and enhancing care transitions.
Moreover, this study seeks to better understand the potential challenges and barriers that
suit a roadblock for a transitional nurse. By elucidating this information, this study can shed light
on current and pervasive obstacles and contribute to the expansion of practices that can target
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challenges that can provide more robust support to these nurses enabling them to offer better and
viable care for their patients.
Research Questions
1. What are the key factors contributing to patient readmissions, and how can transitional
nursing interventions address these factors?
2. What specific strategies and interventions have proven effective in reducing patient
readmission rates across different healthcare settings?
3. How can transitional nurses improve communication and collaboration among
healthcare providers, patients, and families to facilitate seamless care transitions?
4. What are the potential barriers and challenges faced by transitional nurses in their
efforts to reduce patient readmissions, and how can these be mitigated?
5. How can the findings of this research inform the development of evidence-based
guidelines and protocols for transitional nursing practice?
Master’s Essentials Aligned with the Topic
This research topic aligns with several Master’s Essentials, emphasizing the importance
of nursing leadership, evidence-based practice, and interprofessional collaboration in improving
patient outcomes and advancing the nursing profession (American Association of Colleges of
Nursing, 2017).
1. Essential I: Background for Practice from Sciences and Humanities
– Understanding the complex factors contributing to patient readmissions requires a
comprehensive understanding of various disciplines, including biology, psychology, and
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sociology. Transitional nurses must possess a deep understanding of the interplay between
physical, emotional, and social factors that influence patient outcomes during care transitions.
2. Essential II: Organizational and Systems Leadership
– Transitional nursing involves coordinating care across multiple settings, necessitating strong
organizational and systems leadership skills. Transitional nurses must navigate complex
healthcare systems, facilitate effective communication among various stakeholders, and advocate
for system-level changes to improve care transitions.
3. Essential III: Quality Improvement and Safety
Reducing patient readmissions is a key quality improvement initiative that directly impacts
patient safety and well-being. Transitional nurses contribute to increasing the overall quality of
care, and they promote patient safety throughout the continuum of care when they address
readmissions.
4. Essential IV: Translating and Integrating Scholarship into Practice
The purpose of this research is to change scholarly findings into evidence-based practices for
transitional nursing to improve patient care. Transitional nurses will be able to incorporate the
latest evidence-based interventions into their clinical practice to enhance care transition by
synthesizing the evidence on this topic.
5. Essential VII: Interprofessional Collaboration for Improving Patient and
Population Health Outcomes
Successful care transitions require seamless interprofessional collaboration among
healthcare providers, patients, and families. Essential to this process is the role of the transitional
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nurse, who fosters open communication, coordinating the patient’s plan of care across the
healthcare continuum and ensuring that all stakeholders engage in the transition.
By aligning with these Master’s Essentials, this research project underscores the
importance of transitional nursing in addressing the critical issue of patient readmissions and
fulfilling the nursing profession’s commitment to deliver high-quality, patient-centered care.
Through a thorough explication of the challenges, strategies, and best practices in transitional
nursing, this study has the potential to yield important insights and make recommendations to
help inform future policy, protocols, and educational programs – ultimately enhancing patient
outcomes and the quality of care overall.
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References
American Association of Colleges of Nursing. (2017). The essentials of master’s education in
nursing. March 21, 2011.
https://www.aacnnursing.org/Portals/0/PDFs/Publications/MastersEssentials11.pdf
Centers for Medicare & Medicaid Services 2023 retrieved from:
https://www.definitivehc.com/resources/healthcare-insights/average-hospital-
readmission-state#:~:text=The%20average%20hospital%20readmission%20rate%20is
%2014.5%25.,to%2022.3%25%20in%20the%20U.S.
Kim, S. O. and Kim, J. (2021). Association of work environment and resilience with transition
shock in newly licensed nurses: a cross‐sectional study. Journal of Clinical Nursing,
30(7-8), 1037-1045. https://doi.org/10.1111/jocn.15649
Sili, A., Zaghini, F., Monaco, D., Molin, A., Mosca, N., Piredda, M., … & Fiorini, J. (2023).
Specialized nurse-led care of chronic wounds during hospitalization and after discharge:
a randomized controlled trial. Advances in Skin & Wound Care, 36(1), 24-29.
https://doi.org/10.1097/01.asw.0000897444.78712.fb
Weiss, M., Yakusheva, O., Bobay, K., Costa, L., Hughes, R., Nuccio, S., … & Bang, J. (2019).
Effect of implementing discharge readiness assessment in adult medical-surgical units on
30-day return to hospital. Jama Network Open, 2(1), e187387.
https://doi.org/10.1001/jamanetworkopen.2018.7387
Wong, J. S. W., Wincy, W. S., Cheng, M. T. C., Cheung, C. K., Cheung, T. Y. J., Lee, K. Y., …
& Yip, S. L. (2018). Challenges of fresh nursing graduates during their transition period.
Journal of Nursing Education and Practice, 8(6), 30.
https://doi.org/10.5430/jnep.v8n6p30
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