The Importance of Transitional Nursing for the Elderly People

Elderly people (70+ years) are among the most problematic patients in the healthcare system, due to the significant multifaceted healthcare needs that they have. At the same time, transfer across care levels is a very complicated process that causes additional stress among vulnerable patients. It is considered a difficult stage in the patient transition between various levels of medical care, as many unpredictable events can happen. Thus, it is crucial to satisfy the needs of the elderly people during the transition care and to make the transition care more comfortable and less stressful. Overall, this research study investigates, explores, and analyses the transitional care of the elderly people at Jackson Memorial Hospital and Mercy Hospital in Miami. In particular, the main goal of this study is to collect data and to find the challenges and problems associated with the transitional nursing of elderly patients. The necessary recommendations for the improvement of the transitional nursing of elderly patients are provided.

Introduction to the Problem

Transitional care and patient handover are vital spheres, addressed by the World Health Organization to improve the quality and effectiveness of the healthcare sector across the globe. The transitional care is a set of special actions developed to improve the coordination and communication during the patients’ transfer between different levels/locations (for example, from hospital to the nursing home). There are several transitional care services and programs that were specially developed to improve the quality and to reduce the costs of health-care services. Transition care seeks to promote health care continuity and prevent the patient from the poor transition outcomes. In particular, such services are helpful for the patients with complex chronic conditions and elderly people. They are among the most vulnerable patients and can face a lot of stress and difficulties during the transfer from one level of medical care to another. Thus, the main aim of transitional care nursing is to reduce the risk of adverse effects on the patients and improve their general well-being during the process of transition. The current research study focuses on transitional nursing for elderly people, its importance, the challenges and risks associated with it and the methods for its improvement.

Identification of the Problem

Different health care providers, with various spheres of competence, can offer acute and long-term care and treatment for the elderly patients in the United States. At the same time, there exists a problem with the cooperation between healthcare providers, which significantly complicates the process of transition between various levels of medical care. In addition, Alstveit-Laugaland (2015) remarks that one in five patients faces adverse issues due to the hospital discharge or transition to another healthcare institution. Nowadays, the elderly patients (people ≥80 years of age) represent the fastest growing age category in the United States and Europe (Rustad, Furnes, Cronfalk, & Dysvik, 2016). Moreover, elderly people are more prone to the development of the chronic diseases (for example, dementia, stroke, renal failure, metabolism disturbances, and others) that, in combination with social suffering, isolation, lack of physical activity, and multiple medications, can make the transition process more complicated. The researchers Rustad et al. (2016) note: “The older generation themselves tend to meet their situation with an attitude of acceptance and a denigration of their own needs, which masks their vulnerability in the care-transition process” (p.770). At the same time, a number of potential intervention techniques have been developed to manage the current risk factors and control the quality of transitional care of the elderly patients (Storm, Siemsen, Laugaland, Dyrstad, & Aase, 2014). For example, the researchers Storm et al. (2014) underline the importance of the organizational interventions (for example, discharge protocol, discharge planning, utilization of the modern electronic tools, etc.), profession-oriented interventions (for example, additional education and training), and patient- and next-of-kin-oriented interventions (for example, discharge support, patient awareness and motivation, and others). Overall, the transitional nursing for the elderly people is significant and requires special attention and additional research from the scholars due to the existing gaps.

The Significance of the Problem to Nursing

Care transition is being justly considered as a difficult stage in the patient journey between various levels of medical care, since a number of unpredictable adverse events can happen on this rote. Numerous research studies show that there is a significant age-related difference during care transition for the patients of different ages (Rustad et al., 2016). At the same time, the care for the oldest patients is complicated and requires special attention to this issue from the nursing side. Thus, it is important to meet the needs of the elderly people during the transition care to provide them the high-quality services. In addition, the problem is significant to nursing, as a set of discharge-related negative issues can happen during the transition process (for example, adverse drug events, the provision of wrong health and social care, incomplete medical tests, and others (Alstveit-Laugaland, 2015). The researchers have identified three major reasons for the negative outcomes. First is characteristics of the hospital care system (for example, lack of patient education, problems in communication between the nurses and the patient, lapse in the home assistance, etc.) (Alstveit-Laugaland, 2015). Next, is the patient’s characteristics (for example, medication adherence, language barriers, etc.) (Alstveit-Laugaland, 2015). Finally, it is characteristics of the medical personnel (for example, prescription of the wrong medication, inappropriate discharge, and others) (Alstveit-Laugaland, 2015). At the same time, most of these errors can be easily prevented or eliminated with the help of the well-planned transition care process and nursing education.

Purpose of the Research

Taking into account the existing knowledge gaps in literature, this paper seeks to extend, explore and evaluate the current knowledge of transitional care of the elderly people and the factors that influence it at the small-scale and large-scale levels. In particular, this paper has the following purpose that is represented in details through the related research questions. The main goal of this study is to document the current knowledge base concerning the transitional care of the seniors, the main risks, problems and opportunities associated with it, as well as to provide the innovational understanding of the problem and present the suitable methodological approaches and interventions to address those issues.

Research Question

The research question of this paper is the following: “How to reduce the negative consequences of transitional nursing on elderly patients and the possible recommendations to improve the situation?”

The Essentials of Master’s Education in Nursing

There are several Master Essentials that align with the given research topic. In particular, the theme relates to the quality improvement and safety (essential III), as the paper seeks to find out how to improve the transitional nursing (The American Association of Colleges of Nursing, 2011). It relates to translating and integrating scholarship into practice (essential IV) because the paper seeks to find not only theoretical, but also practical solutions of the transitional nursing of the elderly people (The American Association of Colleges of Nursing, 2011). Finally, the theme relates to the inter-professional collaboration for improving patient and population health outcomes (essential VII) as transitional nursing of elderly people unites different parties of the healthcare system (The American Association of Colleges of Nursing, 2011). All in all, it is possible to state that the evidence demonstrates that the theme of this research aligns with the master essentials in many different ways.

Methodology and Design of the Study

The part of the study presents the background information concerning the selection of the participants, settings, and methods of the research of the transitional nursing of elderly people. The study design comprises the two main phases that are represented below in the figure 1. The first one is the literature review. Taking into account the lack of research of transitional care (especially, in relation to elderly people), the design of this part of the study is mainly explorative, descriptive, and explanatory. It answers the “why”, “what”, “where”, and “how” questions to provide the general and comprehensive understanding of the problem in all its representations. The sources for the literature review would be carefully and attentively chosen. In particular, only the recent sources from the last 10 years would be used. Such an approach would help to avoid outdated studies and further utilization of invalid information. Apart from that, only the scholarly sources from the academic libraries and databases would be analyzed. It would give the possibility to get high quality and peer-reviewed information to ensure the reliability of this study. The qualitative content analysis would be made to investigate the basic information about transitional nursing of the elderly and all the factors and problems that are associated with it. The analysis and evaluation of the other studies might give the possibility to find the gaps in knowledge and understanding of the transitional care of the elderly people, thus showing the potential ways and methods of its complementation. In addition, the realization of the literature review would support the objectives of the study and logically lead to the second phase of the research, which is a qualitative case study that employs individual interviews and qualitative case study as a primary research method (see figure 1).

The case study method is relevant for this type of research, as it gives the possibility to obtain not only theoretical, but also valuable practical data about the transitional care of the elderly people and the potential problems associated with it (Cronin, 2014). In addition, the case study method allows making certain conclusions concerning the quality of provided care in the region and compare it with other locations within the United States or even outside of it. In particular, this research would focus on the evaluation of Jackson Memorial Hospital and Mercy Hospital in Miami. The choice is determined by the fact that they are among the largest and most reputable healthcare institutions in the region. The realization of the case study analysis seeks to fill the gaps in the knowledge identified during the literature review and test the preciseness of the results obtained during the previous research phase.

The interviews would be realized, taking into account both sides of the issue (the elderly patients from one side and the nurses, physicians, and other healthcare specialists from the other side). The privacy of all the participants would be ensured, and the confidential information would not be disclosed. The key goal of the interviews is to investigate the existing problems that the elderly people and health representatives face to find the possible solutions to them. All the interviews would be conducted in face-to-face format or via Skype, depending on the choice of an individual. The participants would also be asked to rate the quality of transitional care that was provided according to 100-point scale. Then, the answers of the healthcare professionals and elderly patients should be compared to evaluate the common and different features and understand whether the two sides are objective in their responses.

Of course, in the qualitative study, the trustworthiness of the data and even research results directly depend on the researcher, his/her background, points of view, interests, and biases (LoBiondo Wood & Haber, 2017). Taking this into account, the researcher should try to be as neutral and objective as possible and avoid the personal opinions that are not supported by the facts.

Sampling Methodology

The sampling methodology of transitional nursing of elderly people is presented on the following table (see table 1).

Table 1. The sampling methodology for case study observation

The moderate participants observations would be used for the case studies, as there would be no direct interaction with the participants. From one side, such an interaction gives the possibility to participate as well as be identifiable and present, while from the other side, there would be no interaction (or occasional interaction) that allows the researcher to observe the process of discharge from different perspectives and locations (DeWalt & DeWalt, 2011). In other words, the moderate participants’ observations would perfectly fit the goals and objectives of the current research. Two main types of transitions would be observed within this research. The first would be the admission of the elderly people to the hospital from the home-care service or nursing home (municipality) and the discharge from the hospital to the home-care service or the nursing home. The observation process would be realized discreetly and consecutively with the detailed presentation of the observation notes. Such observation notes would be written in the notebook and would be the combination of descriptions of individuals/groups, direct quotations, and personal impressions. The direct quotations would be used to avoid the misinterpretation and wrong understanding of the information. Based on the written notes, the summary of the observation process in the electronic format was prepared. In the course of preparation of the summary, the discharge summaries might be used (only the ones that would be obtained via the consent of both the healthcare facility and the patient).

At the same time, the interviews would be realized based on the convenience sampling (meaning that the individuals that live and work territorially close to the researcher would be interviewed and analyzed). In other words, I would communicate with people that are easy to access from where I live. According to Etikan, Abubakar-Musa, and Sunusi Alkassim (2015), the utilization of the convenience samples is appropriate for studying different social issues and challenges. The utilization of convenience samples for transitional care of the elderly people is also appropriate for this research, even taking into account the weaknesses of this type of sampling (it provides only partial understanding of the problem) (Price, 2013).

Necessary Tools

For the search of the information, the Google Scholar tool was utilized. It is free, qualitative, and provides the relevant results for this research. Microsoft Word program was used for writing the information on the topic. For storing this research and the articles of the other scholars that were used for completing this study, the author used the Google Drive tool.

The Algorithm of Transition of Elderly

The sample algorithm of nursing transition of the elderly people is presented in the figure 2 below.

Figure 2. The algorithm of transition of the elderly people

It is visible that this algorithm is simple, clear, and understandable. In addition, it is easily applicable and implementable in real life situations.

Pre-Implementation Process

In order to realize the implementation, it is necessary to do the pre-implementation assessment. During the assessment, it is important to identify the main facilitators and barriers to implementation and comprehend the organizational process of the intervention. The main barrier to implementation of the research is institutional regulation. The healthcare establishments may limit the access of other people to observation of the patients, even in the process of entering or quitting the building. However, the presentation of clear and understandable letter with clarification of educational purposes of the study may help to get partial or full access to free observation. At the same time, if the medical employees know that they are being observed, it is likely that they would try to be more attentive with the patients and do their job better than before. Apart from that, there is a probability that careful and attentive attitude towards the patient is not a result of camera, but a common and standard care that is provided equally for everyone. In other words, the obtained results would be trustworthy, but can potentially contain partially untruthful information due to human factor. Another barrier that may arise is the lack of wish of people to share the information and opinions about the problem. All in all, it is important to state that the barriers to implementation are not strong enough to prevent the project from realization. In addition, there are many facilitators of the research. In particular, one may see that the methodology allows to complete the main goals and objectives in the relatively easy and quick manner.

Implementation Process

The following stage is the implementation phase of the research. During this stage, it is necessary to track the transition of the nurse training, the enrollment of the patient, the external and internal facilitation, as well as feedback and audit of the research process.

Table 2. The timetable of the research

During part one of the research, the literature review on the topic will be realized. The author will visit the library and work with the online sources. The phase would take around one month of active academic research, synthesis of information, its analysis, as well as evaluation. The author will gather all this data, categorize it, and present it in the electronic form. The classical literature review stands on the following pillars: “identifying information needs, scoping information available, planning a logical search for information, gathering relevant information, evaluating information sources, managing the process, presenting findings” (Hart, 2018, p.xiii). The author plans to use the same approach, while making the research. It is important to follow certain academic guidelines in the course of realization of the literature review, as otherwise, the quality as well as reliability of the study may not be trustworthy. Generally speaking, according to Merriam and Tisdell (2015), the literature review significantly strengthens the research study, thus making it more profound and objective.

For the research of the relevant literature on the theme of the importance of transitional nursing for the elderly people in the reliable databases (PubMed, Google scholar, and JSTOR) the following keywords would be used: “transitional nursing,” “transitional care of the elderly people, “transition care process,” “patient handover”, “older patients”, “continuity of care”, and others. Only the sources published in the last 7 years will be used in this research to ensure the up-to-datedness of the research study. Overall, the author will try to conduct the literature review, according to the abovementioned principles, hence making it credible and influential source about transitional care of the elderly people.

During part two of the research, the author will visit Jackson Memorial Hospital and Mercy Hospital in Miami to communicate with the relevant representatives of these healthcare institutions. In particular, the author will talk to the personnel responsible for the transition of the elderly people and will ask them about the procedure of the transition process of elderly people in their medical institutions. During the interviews, the researcher will also get the data on the formal protocol of the transition process. Apart from that, the personnel will be asked to evaluate the quality of transition system and offer the recommendations of qualitative improvement. The elderly patients (70+) will be also interviewed concerning their past and future transition experiences. These individuals will be asked to rate the quality of the transition process, as well as mention the main problems and challenges that are associated with it. The elderly people will be asked to offer the recommendations concerning the improvement of the transition process, based on their own experience. The author will record the interviews through the rented voice recorder and will write down the most important parts and messages. Then, all the interviews will be written in the electronic form. The unnecessary or irrelevant information would be deleted and omitted, as people in the interviews may move from one topic to another and just tell the stories that are not directly relevant to the topic. Then, the interviews will be structured and categorized in certain order to achieve the proper flow of the information and the possibility to move to the following stage.

Apart from that, after understanding all the practical and theoretical peculiarities of the transition process through the literature review and interviews, the author would conduct the observation process. In particular, the researcher will go to the Jackson Memorial Hospital and Mercy Hospital in Miami and would observe the transition processes of the elderly people to and from these medical establishments. After the process of observation is finished, the author will write down the results and the most important points in the report. If the photos are necessary, the author will make pictures by phone. However, the permission from the patient to use it for the research will be asked. Apart from that, in each photo, the face of the patient will be blurred for the purposes of confidentiality. According to Merriam and Tisdell (2015), observation method can be criticized for the highly subjective, selective, and unreliable nature of perception of the human. For instance, the traffic accident on the busy road will be interpreted differently, depending on the participants. Thus, taking this factor into account, the author believes that in order to become good systematic observer, it is necessary to study how to write descriptively, as well as which factors to pay attention to in order to distinguish the trivia and the detail. The author will read and learn the relevant literature concerning the proper realization of observation process with minimum of errors to research and evaluate the quality of transition of the elderly people. According to Merriam and Tisdell (2015), observations and informal interviews are classical and most used tools of qualitative research, as they create the perfect academic methodological combination. In this way, despite certain flaws, the methodological choice in this research was chosen appropriately.

Part four, unification of all results of the research, may seem easy at the beginning; however, in the reality, it is one of the most important parts. It is not only the process of putting information in certain order. It is uniting all the data under the single topic, thus making the necessary accents, as well as deleting the information that does not help to achieve the goals and objectives of the research. The part helps to make the text look coherent, relevant, and smooth. Without the process of unification, the text would look like three different independent parts. In addition, this part demonstrates the meaning of all this information and the conclusions made based on the available theoretical and practical data.

The Budget of the Research

The budget of the research is reflected in the table #3.

Table 3. The Budget of the Research

The topic of transitional nursing is not new, and there are many sources devoted to it; however, many of the recent articles and books are not free to access. Thus, in order to make this order up-to-date and objective, it will be necessary to buy the paid access to the articles and other literature sources. At the same time, it does not mean that the whole research is based on the paid sources only. The majority of literature will be obtained free of charge through the Google Scholar database.

The transport expenses are included in the budget, as the author will need to use transport for realizing observation and interviews in the different healthcare settings and with various people all across the city. The rental of voice recorder is absolutely necessary, as it will help not to miss important information provided by the participants of the interview. As it was previously mentioned, the author will write down the main points of the conversations and the discussions, but voice recorder would help to remind the context and additional details. Finally, the paper, pens, and additional small expenses that may arise in the course of conducting the study are included in final calculations. The amount of $80 is not large; however, the money would help in the case of necessity. Finally, the total budget of this research is $500, which is not enough for such type of the study.

Results of the Research

The research study was conducted between July 2018 and October 2018. Two large Miami hospitals were involved in the study. During the process of research, the elderly patients and the healthcare providers, mainly nurses, from the Jackson Memorial Hospital (2018) and Mercy Hospital in Miami (n.d.) were observed and investigated. Six follow-up meetings lasting from 1.5 to 3 hours were conducted in two hospitals, with three visits per one hospital. The follow-up meetings included 16 transitional care nurses, hospital nurses, or community-based patient coordinators, with 8 members selected from each hospital overall. Only one researcher performed the data collection, being responsible for asking questions, making necessary notes, and conducting an audio-recorded session for its further analysis at home.

The results of personal observation and the conducted interviews clearly showed that the level of transitional care given to elderly people is very high in both hospitals. The results of the study demonstrated that only several patients faced the small negative impact of the transition from one hospital facility to another. Moreover, the interviews show that almost 65% of the respondents feel that they receive the essential and high-quality assistance and support from the medical and administrative personnel of these two hospitals.

When discussing the participant observation, it is important to remark that it included open-ended and interactive short conversations with patients and medical personnel and the researcher’s personal observations. The researcher reviewed 12 discharge patient cases, with 1.5-5 hours spent on observation per case in the Jackson Memorial Hospital and 13 discharge patient cases, with 2-4 hours spent on observation per case in Mercy Hospital in Miami. Participant observation was conducted in relation to the discharge transitions, based on the previously prepared observation guide. The main attention was placed on the following themes: interdisciplinary collaboration, documentation and information, conversation and coordination with other care providers and with the patient, time factors, stressful situations, and other similar elements. In addition, demographic data related to patients and medical personnel were analyzed and evaluated. Each observation of the discharge case started in the morning of the day of patient’s discharge and ended with a short conversation with the involved medical personnel and the patient.

From the observation, it can be seen that generally, the process of transition of elderly people was not an overly stressful or challenging experience. Some patients looked or felt uncomfortable due to the lack of understanding of the discharge process and the related administrative procedures. At certain moments, there were some challenges in communication between the medical personnel and the patients. The communication problems were mainly caused by the human factor, however, they did not affect the overall quality of transitional care.

Regarding the interviews, it is important to remark that in total, the researcher conducted 16 interviews with the medical personnel from two hospitals. In addition, eight elderly patients, six women and two men aged 83-92 years, agreed to participate in the research project and to give the interview about their personal experience of the discharge to another healthcare facility. Thus, eight patients with different diagnoses, such as cancer (four patients), stroke (three patients), and pneumonia (one patient) took part in this research. Unfortunately, two patients, one man and one woman, later withdrew from the research project due to personal reasons and deterioration of health after moving to another place. The background data about the patients’ age, gender, type of care transition, and disease are represented in Table 4.

Table 4. Background data of the research study participants (patients), n=8

All the interviews were conducted by the author of this research study. The author contacted the patients by phone or Skype one week after the transition from the hospital to their home or to a nursing home to make an appointment for the interview. All the performed interviews lasted for approximately 30-45 minutes and had only open questions to provide more answer freedom for the participants. Thus, all the former patients had the chance to speak freely about their experiences, both positive and negative, and their recommendations and suggestions. Two participants were interviewed at the nursing homes and five participants were interviewed at home. At the same time, four of the interviews were performed with the presence of at least one member of the participants’ family at their request. All the participants provided their agreement to record their interviews and to use them in this research project.

From the interviews with the patients, it can be seen that there are several problems in the organization of the transitional care in the Jackson Memorial Hospital and Mercy Hospital in Miami. Firstly, all the patients described the care transition from the hospital to their home or to a nursing home as a complex procedure that was stressful for them. Also, three patients remarked that they had problems with communication with nurses, as they were poorly informed about the entire discharge process. Furthermore, one of the participants remarked that there were certain misunderstandings between the hospital personnel and the personnel at the nursing home. Moreover, five participants mentioned that they were confused due to the unknown terminology in the signed documents. It was difficult for their understanding and there were no additional explanations. Also, two of the participants noted that they wanted to have more opportunities to be in charge of their own situation because the healthcare providers limited their actions. At the same time, despite the small problems, all the participants remarked that they felt safe when they left the hospital due to professional actions of the healthcare providers.

Through my communication with nurses, I determined that they have problems with transition of the elderly people who are not psychologically stable in relation to the surrounding world due to their age and disease. Even though the medical personnel do everything possible in order to explain the transition process to the patients and try to make it more comfortable and less stressful, the patients still fail to react positively. In addition, the nurses claimed that practically any change is usually stressful for elderly patients, as it takes them out of their comfort zone. At first, the elderly patient feels stressed from coming to the hospital from home, then he/she gets used to the life in the hospital and to the high level of care and, thus, feels stressed again due to the need to return home, where very often, nobody waits for them. Overall, the study demonstrated that age is often a challenge in the process of transition as the elderly represent one of the most vulnerable parts of the population.

The comparison of the feedback obtained from the elderly patients and from the medical personnel demonstrated that overall, the transition process to and from the medical establishments is realized in a high quality manner. Naturally, the challenges and problems exist – however, they are not significant. Still, it is possible to reduce the negative consequences of transitional nursing for elderly patients in the following ways. Firstly, it is important to improve the channels of communication between the patient and the healthcare providers during the discharge process. Secondly, it is necessary to determine certain responsibilities of the transitional care personnel that are currently vaguely stated. Finally, since the elderly are the vulnerable part of the population, there should be additional attention paid to them during the process of transition, as compared to non-elderly population.

Regarding the limitations, it is possible to state that the research study was limited by the small number of participants and the number of healthcare facilities that were analyzed. The findings cannot represent the entire picture of the transitional care nursing for the elderly in the United States, as the sample size is not big enough (Chow, Shao, Wang, & Lokhnygina, 2017). In addition, the research study investigated only the patient’s discharge stage, while to get more accurate data on the elderly patients’ transition outcomes, it is important to analyze the results not only in the day of discharge, but also to make follow-up visits to the patients in several days to get information in a calmer atmosphere. Lastly, a researcher’s bias is possible as the research study was performed by a researcher with a nursing background. It is better to perform the observations and interviews in a team of at least two or three researchers to cover the entire complexity of observation and communication processes with the medical personnel and the patients. However, despite the aforementioned limitations, it is possible to state that the results of the research study on the theme of transitional nursing of the elderly are extensive. Thus, there is a significant potential for future research that can enlarge the current contribution to the investigated question.

Conclusion

This research study identified different aspects of the care transition process in the Miami medical institutions. The findings of the study clearly underlined that transitional care of the elderly is a very complex process with many challenges that caused a certain level of discomfort for the older patients and medical personnel. Overall, the necessary recommendations in order to secure and improve continuity of care and to develop the better practice in serving older patients were provided. Overall, the main goal of this research was achieved, as the negative consequences of transitional nursing on the elderly patients and the possible recommendations to improve the situation were found. Overall, the older patients are very vulnerable part in the transition process and it is important to improve the transition system in the United States to improve the entire transition process and to improve patients’ well-being.

As well, learning experiences from the MSN essentials and from the class significantly helped during the work on this research paper. They provide necessary knowledge in such important areas, as preparedness to the research study, data collection, sampling, analysis of the received data, work with quantitative and qualitative data, search for the study participants, and many others.

Implications for Future Studies

The current research study can be further investigated in future, both in terms of depth and scope. This research covers a very limited data, due to the lack of time and financial resources of the researcher. However, it is important to widen the number of medical institutions and the amount of patients and medical personnel involved in the transitional process to expand the results of the study. A further research is needed to get more detailed data about the transitional process of the elderly people and to check the current findings to make necessary improvements if needed.