Identifying Effective Nurse‐Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel

Jeffs, Lianne; Kuluski, Kerry; Law, Madelyn P.; Saragosa, Marianne; Espin, Sherry; Ferris, Ella; Merkley, Jane; Dusek, Brenda; Kastner, Monika; Bell, Chaim M.

doi:10.1111/wvn.12196

Cited by 75 publications

(39 citation statements)

References 39 publications

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“…Most of them found their leaders to be supportive and understanding during the implementation and experienced that leaders took great responsibility in supporting this process. This finding is consistent with other studies demonstrating that having competent and dedicated leaders is a crucial prerequisite to facilitate successful implementation (Jeffs et al, ; Røsstad et al, ; Weberg, ). Although some informants considered the implementation important and necessary, others, including several GPs, seemed not to consider the implementation as valuable and were often more concerned about the efforts required.…”

Section: Discussionsupporting

confidence: 92%

“…Although several informants considered the checklists as a useful tool, the majority of them reported that the comprehensiveness of the lists and the substantial amount of work they required made checklists demanding to follow‐up in practice. Other studies have also found work‐facilitated transitions infeasible due to nurses’ substantial workload and limited time for new paperwork (Chapin et al, ; Jeffs et al, ). Our findings revealed that staff exerted considerable effort to organise their work to enable the use of checklists, and that they sometimes had to skip lists because of heavy workload.…”

Section: Discussionmentioning

confidence: 99%

“…This finding is a critical, but often ignored, point for successful implementation of innovations in the healthcare sector (Jeffs et al, 2017;Røsstad et al, 2015). Without economic resources, innovation in health care is unlikely to occur because innovation takes time, effort, space and human resources (Illinca et al, 2012;Weberg, 2009).…”

Section: The Implementation Processmentioning

confidence: 99%

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Facilitating holistic continuity of care for older patients: Home care nurses’ experiences using checklists

Nilsen

Söderhamn

Dale

2019

Journal of Clinical Nursing

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Aims and objectives To explore home care nurses’ experiences of implementation and use of checklists developed for improving continuity of care for older patients (65+ years). Background The Norwegian Coordination Reform was implemented to improve coordination between hospitals and communities and facilitate a quicker return to home community after hospital discharge. To follow‐up, national learning networks were initialised to improve pathways for chronically ill older patients, including the development and use of standardised checklists. Design An explorative qualitative design was chosen. Methods Three focus group interviews were conducted, including 18 registered nurses from eight municipalities in southern Norway. Systematic text condensation was used to analyse the interview texts. The COREQ checklist was followed. Results Three categories emerged from the analysis. (a) “The implementation process” included the experiences of a chaotic beginning, the importance of involvement, the leaders’ role and resource allocation. (b) “Pros and cons of checklists in use” included the informants’ experiences of checklists’ usefulness for nurses and the patients. (c) “Competence needed” included the need for a comprehensive set of formal, experiential and social competences. Conclusion and relevance to clinical practice The leaders’ role, support and engagement are decisive for a successful implementation. To succeed and establish solid routines, allocating resources when implementing new laborious routines, such as checklists, is important. To improve holistic continuity of care to chronically ill older patients, checklists should be customisable to each patient's needs, be comprehensive enough to grasp the essence in what to be done at several time points, but at the same time brief enough to be operational. Checklists can be a useful tool for home care nurses, if customised to the individual municipality and the staffs’ working routines. It is important that the staff have versatile and extensive competencies enabling them to use the checklists appropriately.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: The Implementation Processmentioning

confidence: 99%

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Facilitating holistic continuity of care for older patients: Home care nurses’ experiences using checklists

Nilsen

Söderhamn

Dale

2019

Journal of Clinical Nursing

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“…Communication tools such as the TRANSITION tool can support conversations between ward‐based nurses and older patients that guide nurses to know what to ask and to find more information. This is significant because the health and functional status of older patients with chronic illness changes across their acute care trajectory and they have different transitional care needs at different stages of their care and recovery (Jeffs et al, 2017; Naylor et al, 2004). The TRANSITION tool may facilitate continued screening and assessments regarding the transitional care plan by ward‐based nurses who could then communicate this clinical information to the allied health and medical teams as required.…”

Section: Discussionmentioning

confidence: 99%

“…Despite the research about communication and transitional care (Hickman et al, 2015; Holland & Hemann, 2011), optimal communication between practitioners, patients and carers remains challenging in practice (Goncalves‐Bradely et al, 2016; Jeffs et al, 2017). This is because there is a range of barriers including limited resources and tools to support communication about care transition needs between healthcare practitioners and older patients (Jeffs et al, 2017).…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the TRANSITION tool to improve communication during older patients’ care transitions: Healthcare practitioners’ perspectives

Allen

Hutchinson

Brown

et al. 2020

Journal of Clinical Nursing

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Aims To evaluate healthcare practitioners’ perceptions of the feasibility and acceptability of a communication tool, entitled the TRANSITION tool, to communicate with older patients during transition from acute care to a community setting. Background Transitional care for older patients is challenging due to their complex care needs and rapid care transitions. Research has identified effective models of transitional care. However, optimal communication between healthcare practitioners and older patients remains under‐investigated. Design Exploratory descriptive qualitative design. Methods The methods are reported using the Consolidated Criteria for Reporting Qualitative Studies checklist. The setting comprised two acute medical wards in an urban hospital in Australia. Twenty‐two nursing and allied healthcare practitioners used the TRANSITION tool to guide communication about transitional care with an older patient and then participated in an interview about their experience of using the tool. All data were thematically analysed. Findings Healthcare practitioners reported their perceptions that the TRANSITION tool was feasible and acceptable, and that they perceived the tool supported them to know what to ask and to find out information regarding their patient's transitional care needs. Some ward‐based nurses reported their perception that transitional care was not their role. Conclusions Findings emphasise transitional care as a continuing care process that requires effective communication between nurses and older patients in acute medical wards. Relevance to clinical practice Given shorter lengths of stay, complex care needs and slow recovery, ward‐based nurses are vital in communicating with older patients about their transitional care needs. The TRANSITION tool may support communication between ward‐based nurses and older patients to improve assessment and planning. Implementation of the tool will require a planned strategy to facilitate translation of the tool into routine practice of ward‐based nurses to support their roles during older patients’ care transitions.

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The use of nurse‐led care intervention to improve self‐care abilities subsequently decreasing readmission in multimorbid hospitalized patients: A quasi‐experimental study in a real‐world setting

et al. 2023

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Aim: Nurse-led care aims to optimize the discharge preparation with a focus on increasing patients' independency and self-care abilities. This study compared patients' improvements of self-care abilities and frequency of readmission rate between nurseled care and regular nursing care within the acute hospital setting.Design: A quasi-experimental design within a real-world setting was used for this work. Methods:We included a pool of 2501 patients from a control group (medically stable in usual care) and 420 patients from an intervention group (nurse-led care). After propensity score matching, the study cohort consisted of 612 patients. Results:From admission to discharge, nurse-led care patients showed superior improvements of total self-care abilities compared to usual care patients. In particular, we found improvements in the following categories: mobility, grooming and excretion.Patients with nurse-led care were furthermore less frequently readmitted to hospital compared with the control group patients.

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Identifying Effective Nurse‐Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel

Cited by 75 publications

References 39 publications

Facilitating holistic continuity of care for older patients: Home care nurses’ experiences using checklists

Facilitating holistic continuity of care for older patients: Home care nurses’ experiences using checklists

Evaluation of the TRANSITION tool to improve communication during older patients’ care transitions: Healthcare practitioners’ perspectives

The use of nurse‐led care intervention to improve self‐care abilities subsequently decreasing readmission in multimorbid hospitalized patients: A quasi‐experimental study in a real‐world setting

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