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Transitional care and patient handover are vital spheres addressed by the World Health Organization to improve the quality and effectiveness of the healthcare sector all 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 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 the transitional care nursing is to reduce the risk of adverse effects on the patients and improve their general well-being during the transition process. The current research study directly focuses on the transitional nursing for the elderly people, its importance, the challenges and risks associated with it and the methods for its improvement.
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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 U.S. 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, Furnes, Cronfalk, & Dysvik (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 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 very significant and requires special attention and additional research from the scholars due to the existing gaps.
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The Significance of the Problem to Nursing
Care transition is justly considered 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 age (Rustad, Furnes, Cronfalk, & Dysvik, 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). Further, the researchers identify three major reasons for the negative outcomes. Firstly, it 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, it 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 thanks to the well-planned transition care process and nursing education.
Purpose of the Research
Taking into account the existing knowledge gaps in the 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 detail 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.
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The main research questions are the following: (1) What is the definition and perception of the elderly in different societies all over the world and what are the specifics of providing transitional care to the elderly people from different countries? (2) What risks and problems are identified by other authors in the literature related to the transitional care of the elderly? (3) What possible interventions and solutions are defined in the literature to address these problems and risks? (4) What problems exist in the hospital discharge system of the elderly people? (5) How to address the problems related to the hospital discharge system? (6) How to reduce the negative consequences of transitional nursing on the elderly patients and what are the possible recommendations to improve the situation?
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 essentials of master’s education in nursing,” 2011). Also, 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 essentials of master’s education in 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 essentials of master’s education in 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.