Case 27

Phase One Paper
Jose Duarte
Florida National University
Nursing Research and Evidence-Based Practice
Instructor: Aciel Sagrera-Mulen
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.
American Association of Colleges of Nursing. (2017). The essentials of master’s education in nursing. March 21, 2011.
Centers for Medicare & Medicaid Services 2023 retrieved from:,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.
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.
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.
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.


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