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Planning for our patients during times of transition (for example hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:
How does your facility promote interprofessional collaboration during times of patient transitions?
What is the role of the nurse inpatient transitions?
What gaps can you identify in this process related to the quality of care?
Integrate my book(American Nurses Association (2015). Nursing Scope and Standards of Practice (3rd Ed.). ANA Silver Spring, MD.) And one outside scholarly source.
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Successful patient transitions are largely dependent on interprofessional collaboration. It entails working together between different health care providers to ensure smooth patient transfer from one setting to another. Doing so is critical to reducing the potential risk of communication associated with the transfer of patient care. Therefore, a safe and effective transfer of responsibility relies on effective communication and patient understanding of discharge instruction. Although it is a health provider’s role to provide effective transitions, health care organizations must initiate measures to ensure success.
Promotion of Interprofessional Collaboration
My organization takes patient care transitions as an important aspect of quality care delivery and engages in regular workshops about proper communication. The assumption is that effective communication is essential among health professionals and in patient instructions (ANA, 2015). Consequently, health professionals utilize care plans and organizational care pathways including a standardized hand-off report. The report provides information about patient response to medical and nursing interventions, the efficiency of the ongoing care plan, patient goals, and outcomes. The efficiency of the approach contributes to effective care transitions in the facility.
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Role of the Nurse
Nurses are an important component of the care transition process. Their interaction with patients during their vulnerable moments means that they often learn critical information about a patient’s life (Camicia & Lutz, 2016). Effective care transitions entail utilizing this information during the transition plan towards success. The role of nurses in my organization is to develop and evaluate transition plans, identify and communicate any challenges. Communicating the barriers to the interprofessional team ensures that they initiate early plans in the patient’s hospitalization towards individualized care. However, stroke survivors often present with significant challenges to nurses in my facility by reporting financial constraints and a lack of familial support post-discharge. Such limitations are a threat to the intended transition plan.
American Nurses Association (2015). Nursing Scope and Standards of Practice (3rd Ed.). ANA Silver Spring, MD.
Camicia, M., & Lutz, B. J. (2016). Nursing’s role in successful transitions across settings. Stroke, 47(11), e246-e249. https://doi.org/10.1161/STROKEAHA.116.012095
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