The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team

Chen, Wei Ting; He, Hong; Chow, Yeow Leng

doi:10.5334/ijic.5838

Cited by 3 publications

(2 citation statements)

References 52 publications

(89 reference statements)

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“…However, TCNCM with this kind of criteria is rare in clinical settings, which may decrease the study application. Nevertheless, past studies reported the TCNCM was essential to facilitate smooth care integration and transition post-discharge [ 43 – 45 ]. Therefore, we highly recommend hospitals arrange a specific TCNCM to help patients during transitional period.…”

Section: Discussionmentioning

confidence: 99%

Improving transitional care through online communication skills training

et al. 2022

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Background As the aging population is increasing significantly, the communication skills training (CST) on transitional care (TC) is insufficient. Aims This study aimed to test the effectiveness of an intervention (the online TC CST [OTCCST] and TC) through the perspectives of healthcare providers (HCPs), older patients, and family members. Methods A total of 38 HCPs caring for older patients were randomized to the experimental ( n = 18) or control groups ( n = 20), and 84 pairs of patients and family members were enrolled (experimental: n = 42 vs. control: n = 42). The primary outcome was HCP communication confidence; while secondary outcomes included patient quality of life (QoL), activities of daily living (ADL), rehospitalization counts, and family caregiving burden. Data were collected from HCPs using a scale measuring confidence in communicating with patients. Patient outcomes were assessed using the McGill QoL Questionnaire-Revised and Barthel Index. Family members were assessed with the Caregiver Burden Inventory. Rehospitalization counts were tracked for 3 months post-discharge. Data were analyzed using multiple regression analysis. Results Experimental group HCPs showed a significant improvement in communication confidence over the control group ( p = 0.0006). Furthermore, experimental group patients had significantly fewer rehospitalization counts within 3-month post-discharge ( p < 0.05). However, no significant group differences were found in patient QoL and ADL nor in family caregiver burden. Conclusion The OTCCST can effectively improve HCP communication confidence, and the combination of OTCCST and TC can reduce rehospitalization counts for older patients. The OTCCST allows HCPs to learn asynchronously at their convenience, ideal for continuing education, especially during the COVID-19 pandemic. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-022-02251-4.

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Section: Discussionmentioning

confidence: 99%

Improving transitional care through online communication skills training

et al. 2022

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“…Effective coordination of care is essential for meeting the evolving needs of individuals. Studies emphasize the role that geriatric nursing plays in managing transitions between healthcare environments (12,13). Older adults often navigate care paths involving caregivers and services, resulting in disjointed care provision.…”

Section: Introductionmentioning

confidence: 99%

Geriatric Nursing In Primary Care: Addressing The Complex Needs Of An Aging ‏Population

Alfaouri,

Alasmari,

Alanazi

et al. 2023

SFS

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The management of patients in primary care settings is a complex and continuously changing task that's essential for meeting the diverse healthcare needs associated with aging. Based on research, the review emphasizes the prevalence of chronic conditions among older adults, highlighting the importance of proactive and systematic approaches to monitor and manage these conditions effectively. Educating patients plays a role in enabling individuals to engage in their healthcare journey actively. Collaboration with pharmacists is vital for optimizing medication plans and ensuring safety. Dealing with decline requires efforts across different disciplines, focusing on collaboration between primary care providers and specialists. Nondrug interventions like stimulation therapy and caregiver education make an impact on improving both patients' and families' quality of life. Addressing limitations, fall risks, and nutritional concerns underscores the need for an approach to clinical care. Physical therapists, occupational therapists, and geriatric nurses work together to develop strategies that address the challenges faced by elderly patients. Effective pain management, mental health support, and end-of-life care emphasize the importance of putting patients at the center of care through assessments and evidence-based treatments. With advancements in research, technology, and interventions in nursing within primary care settings, it's crucial for healthcare professionals to stay updated to provide optimal care.

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Transitional care strategies at emergency department for elderly patients: A multicentre study in Singapore

Leong

Ong

et al. 2023

Ann Acad Med Singap

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Introduction: Transitional care strategies (TCS) initiated for elderly patients prior to emergency department (ED) discharge are important for ensuring effective transition to other care settings. Such strategies have been shown to reduce avoidable acute admissions. This first nationwide study is targeted at public acute hospital EDs in Singapore, and aims to characterise TCS for ED-discharged elderly patients and understand the experiences of healthcare staff in the delivery of TCS. Method: Seven key informants (KIs), one per ED, completed an online structured questionnaire and semi-structured video conference interview from 8 May to 31 August 2021. The KIs were ED specialists and an ED-trained senior staff nurse who were knowledgeable in geriatric emergency care and had contributed to at least one elder-related TCS. Field notes were compiled, transcribed, anonymised and analysed using thematic analysis. Results: All 7 EDs have TCS as “usual care” available during office hours, at no extra cost to patients. Common components of TCS include screening, evaluation with comprehensive geriatric assessment, health education and follow-up telecare. TCS implementation was facilitated by organisational support in terms of established protocols and communication platforms, training and collaboration of a multidisciplinary team, and caregiver involvement. Obstacles faced include fragmented communication between personnel, limited resources, and poor buy-in from stakeholders. Conclusion: Understanding the heterogeneous characteristics of ED-TCS at various hospitals will aid the development of service typology and identify service opportunities. Provider experiences grouped into themes help to inform future strategies for TCS implementation. More research is needed to evaluate patient outcomes and cost-effectiveness of TCS. Keywords: Community care services, emergency department, geriatric medicine, transitional care

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The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team

Cited by 3 publications

References 52 publications

Improving transitional care through online communication skills training

Improving transitional care through online communication skills training

Geriatric Nursing In Primary Care: Addressing The Complex Needs Of An Aging ‏Population

Transitional care strategies at emergency department for elderly patients: A multicentre study in Singapore

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