Caring for older patients who have complicated medical conditions along with potential risk factors is a challenge the majority of nurses face on a regular basis. The introduction of the Transitional Care Model (TCM) allowed nurses to better operate the interventions targeted at addressing the health outcomes of older patients at risk as they move between clinicians or across healthcare settings (Hirshman, Shaid, McCauley, Pauly, & Naylor, 2015). Therefore, it arises a problem of preserving patient satisfaction with the provided care at the same time with maintaining excellent communication and complete transfer of information among healthcare providers.
Because transitional care encompasses a variety of procedures, keeping the entire process under full control is major challenge nurses have to face. If, for example, the communication between health providers with regards to the condition of a patient was inadequate, there will be a high chance of missing valuable information that could be crucial for improving patient outcomes. On the other hand, patient satisfaction is a factor that can have a significant impact on the rating of a healthcare facility in general, thus making sure that a patient is satisfied with the services in situations that call for cooperations between different units or clinicians is a problem that needs to be resolved. Moreover, health literacy problems and language can become barriers to successful Transitional Care Model implementation and may further exasperate the problem, as mentioned by Naylor and Keating (2008).
Problem Significance to Nursing
According to Bowles, Pham, O’Connor, and Horowitz (2010), negative health outcomes among hospitalized older patients have been associated with poor or absent communication, lack of collaboration between the members of a healthcare team, gaps in service when patients move across care settings, as well poor continuity of care. The problem of finding a balance between effective communication among healthcare providers and high levels of patient satisfaction is significant because it limits nurses’ chances of ensuring quality care that would lead to better health outcomes. Very often the duty of nurses to provide care can be exasperated during sudden episodes of acute illness when a patient needs to be immediately transferred to another health care setting. Increased stress levels can potentially lead to poor communication between care providers, which, subsequently, can affect the patient’s chances of being treated immediately.
Purpose of the Research
Research targeted at resolving the identified problem will be beneficial for improving older patients’ outcomes during their transfer between settings as well as enhancing the levels of collaboration between nurses and other health providers that participate in the process of transferring. Establishing and maintaining trusting relationships with the patient, his or her family, as well as caregivers involved in the process is considered a key component of successful Transitional Care Model implementation, as mentioned by Hirshman et al. (2015). Along with collaboration, continuity, and coordination, excellent levels of communication among all members of the team characterize successful TCM implementation. Therefore, there is a high need in studying why and how healthcare providers should collaborate in emergency situations where the health outcomes of a patient depend on their preparedness to effectively share information and react quickly in critical situations.
Research on the problem should encompass answers on research questions that pertain specifically to effective communication among healthcare providers as well as high levels of patient satisfaction within the context of transitional care model implementation. The research will aim to answer the following questions:
Research question 1. How ineffective communication and lack of collaboration among healthcare providers limit a patient’s chances of receiving high-quality care within the context of Transitional Care Model implementation?
Research question 2. What strategies can enhance the implementation of the Transitional Care Model with regards to effective collaboration among the staff members to ensure patient satisfaction and improved health outcomes?
Research question 3. Is there a direct relationship between patient satisfaction and the levels of communication among healthcare providers?
The research questions outlined above are targeted at identifying what strategies can be implemented to improve collaboration between nurses and other healthcare providers in situations that call for quick actions and coordination of these actions between different settings.
Master’s Essentials that Align with the Topic
The problem of maintaining high levels of patient satisfaction while enhancing communication among team members within the context of Transitional Care Model implementation aligns with the following Master’s Essentials:
Essential II: Organizational and Systems Leadership;
Essential III: Quality Improvement and Safety;
Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes (American Association of Colleges of Nursing, 2011).
Essential II aligns with the identified problem because it underlines that leadership plays a significant role in the provision of quality care to patients. The successful TCM implementation is impossible without cooperation and leadership. Essential III aligns with the identified problem because the issue of improving health outcomes among older patients is associated with the enhancement of provided healthcare services. Lastly, Essential VII is the one that is the most closely linked to the identified problem since it recognizes the importance of effective communication and collaboration in a healthcare setting.
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Web.
Bowles, K. H., Pham, J., O’Connor, M., & Horowitz, D. A. (2010). Information deficits in home care: A barrier to evidence-based disease management. Home Health Care Management & Practice, 22, 278-285.
Hirshman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The Transitional Care Model. Online Journal of Issues in Nursing, 20(3), 1-12. Web.
Naylor, M., & Keating, S. (2008). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108(9), 58-63.