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Clinical Nurse Specialists' Perceptions of Transitioning Into a Rural Community-Based Transitional Care Role

Cross, Kristi L. DNP, RN; Johnson, Paula MSN, DA, RN; Allard, Billie Lynn MS, RN, FAAN; Shuman, Clayton J. PhD, RN

Author Information
JONA: The Journal of Nursing Administration: September 2020 - Volume 50 - Issue 9 - p 456-461
doi: 10.1097/NNA.0000000000000916
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In an effort to align healthcare delivery with payment reform, many nursing leaders are recognizing the value of enhancing care for individuals with multiple comorbid conditions.1 One approach has been to develop transitional care nurse (TCN) programs to address care gaps during transitions of care. Transitional care nurse programs are different from standard transitional care interventions because they are more comprehensive, complement primary care and chronic care management, and involve a nurse-led multidisciplinary model.2 Transitional care nurse programs have been shown to increase quality outcomes and decrease costs,3 which aligns well with the priorities of value-based care. Clinical nurse specialists (CNSs) are ideal candidates for TCN roles because the position requires a primary coordinator of care with expertise and experience in clinical and managerial skills.2


Transitional care nurse programs are important under healthcare reform because they reduce spending and increase quality care.3 Most TCN programs are nurse led, typically target a chronically ill population, include goals that avoid preventable poor outcomes, and are time limited with a formal discharge.3 Although TCN programs have been shown to decrease cost, such programs are challenging to sustain and require additional research to improve implementation and sustainability of TCN programs so that healthcare organizations and patients can achieve intended benefits.4

The implementation of transitional care approaches often involves role transitions for nurses (eg, from hospital based to community based).5 The shift from volume-based care to value-based care may threaten the sustainability of the CNS roles in acute care because of changes in healthcare infrastructures.5 In light of nationwide changes to the CNS role, especially in smaller, rural community hospitals where resources are more strained, TCN programs offer an opportunity to reallocate the expertise of CNSs, retain CNS staff, and improve patient outcomes.6

Challenges associated with role transitions can threaten the sustainability of programs.6 Given the concerns on program sustainability and the methods of reallocating CNSs into a TCN role, a more comprehensive understanding of the experiences of nurses transitioning into the role is vital. However, little research has addressed the experience of nurses moving from hospital-based positions to TCN roles. Therefore, the purpose of this study was to understand the experiences of nurses making the role transition from CNS (hospital based) into TCN roles (community based). Our specific aims were to describe TCNs' perceptions regarding: 1) their role and responsibilities in the TCN program; 2) training and onboarding; and 3) organizational support provided to the TCN program.



A qualitative descriptive design was used to explore perceptions of CNSs who transitioned into a TCN role. Institutional review board approval was provided by the study site before the start of any research-related activity.

Participants and Setting

Participants were recruited from a small rural community hospital in Vermont. The hospital developed and implemented a TCN program in 2011.7 This involved transitioning CNSs into a TCN role. Inclusion criteria for participants were 21 years or older, currently employed as a TCN or previously worked as a TCN within the last 2 years at the study site, worked at least part-time (minimum of 12 hours/week), worked more than 6 months as a TCN at the study hospital, and English speaking.

The director of the hospital's TCN program provided email addresses of current and previous TCNs. The principal investigator (PI) of the study sent eligible nurses email invitations to participate in the study. The email provided information regarding the study, with instructions on how to enroll, along with the informed consent document for review. Each participant was assigned a unique identification code to protect confidentiality. Interviews were scheduled at a mutually agreed upon date and time and conducted by the PI in a private office located in the study hospital.

Data Collection

Data were collected in May 2019 via in-person interviews using a semistructured interview guide. The interview guide was reviewed and critiqued by 2 members of the research team and included 17 open-ended questions with probing questions. Each interview was conducted by the principle investigator, audio-recorded, and lasted between 45 and 60 minutes.

Data Analysis

All interviews were transcribed verbatim and reviewed twice and checked for accuracy before data analysis. Data were analyzed using the constant comparative methods of Glaser and Strauss.8,9 Two members of the investigative team individually performed initial analysis for minor themes. These themes were compared and discussed until all members reached agreement. Minor themes were organized into major themes. The major themes were compared and discussed until all members reached agreement via an in-person meeting. Rigor was established through trustworthiness.10 Trustworthiness was achieved by assuring credibility, dependability, and confirmability through peer debriefing, discussion, and engagement. Peer debriefing occurred between 2 investigators during data analysis. To ensure that data analysis was appropriate and just, investigators engaged in reflective discussion, debate, and consensus on the perceptions of the participants.10


Five of the 6 eligible TCNs participated in the study. All participants were women and white. Four participants were masters'-prepared RNs. Three of the masters'-prepared RNs were in their CNS roles for more than 20 years. Eighty percent of the participants were in the TCN role for more than 2 years (Table 1). Seven major themes emerged from the data analysis: a) enhanced patient-centered care; b) collaboration among the other TCNs; c) transitioning from expert to novice; d) recommendations for navigating and negotiating systems; e) discomfort with the role transition; f) a level of altruism and autonomy; and g) recommendations for improving the TCN role. Minor themes supported each of these major themes (Table 2).

Table 1
Table 1:
Participant Demographics (N = 5)
Table 2
Table 2:
Major and Minor Themes

Enhanced Patient-Centered Care

Participants appreciated that the TCN role gave them greater opportunity for reviewing patient medical records and case conferencing before meeting the patients. The participants felt that their patient assessment and teaching extended traditional assessment and teaching done in the hospital. One participant described it as being “bigger than just physical assessment and teaching. It's about understanding and trying to help someone that is struggling and trying very hard to make ends meet and trying to find resources for the long term to cover those needs.”

Participants described the unique and complex needs of patients receiving transitional care, particularly regarding their living condition and social determinants of health. For example, 1 participant stated, “There were days when it was a little scary. Because as experienced as I was and as accustomed as I was going into not ideal conditions, it was still overwhelming some days to think about the depth of needs and to figure out how you would work with that patient to put together a safe plan.”

All participants described improved relational components between patients, families, caregivers, and TCNs because of the TCN program. These relational components included increased patient vulnerability and comfortability in discussing health concerns, which resulted in time to build rapport in the home, and establishing a special connection with patients and their families. One participant shared, “I think it broadened me. It gave me a different relationship with my patients. A much deeper relationship and one that I carry with me, much more than I did when I was a hospital nurse.”

Collaboration Among the Other TCNs

All participants discussed unique dynamics between the TCNs at the hospital. Some had been previous colleagues in their CNS roles, so they had already developed rapport and trust. This foundational relationship was instrumental in not only developing the program but also described as positively impacting their transition into the role. For example, the TCNs felt a sense of comradery and that they were in it together as team. One described it as, “We always had each other.”

Previous experiences working together helped to develop trust and reliance in each other and allowed participants to understand each other's learning needs during the transition. This trust paved the way for a safe space for impromptu debriefings with each other. One described debriefing meetings as a “valuable part of our team.” Another stated, “We were colleagues for many years. So we already had a supportive network of CNSs who had each other's backs through everything… And that did not end when this started. In fact, it became stronger.”

Transitioning From Expert to Novice

Participants described the transition into the TCN role as “moving from expert to novice.” This was further elaborated as feeling that the position provided a bigger picture outside of the hospital walls. One participant stated, “There was a bigger picture out there…we did not see that in acute care setting. It was easy to provide discharge instructions and expect that they would follow through.”

The shift from episodic care in a hospital setting to postdischarge community-based care including social determinants of health left many participants feeling unprepared. One participant explained, “I was an expert in my field and now I was not an expert in my field, where I had to learn on the fly.” Another participant explained that the transition “moved me from my very comfortable position to now out in the field…making decisions based on what I'm seeing.”

All participants described the challenge of not knowing when to transition patients off transitional care. Participants described it as the following: “The hardest thing is figuring out when it's time to let them go” and “I probably kept a few patients a lot longer that I should have according to the guidelines that we set up. They were needy and had very little support and basically they did not want me to stop seeing them.”

Recommendations for Navigating and Negotiating Systems

Dovetailing off the transition from expert to novice is the challenge of navigating and negotiating systems. First, participants relayed that, as TCNs, they identified a gap in service. The populations they served were falling into a gap of not qualifying for home health services, but needing some type of service to transition from hospital to home. One participant described it as, “One of the things that really drove us to this transitional care program was hearing in discharge rounds that patients were going home without needs. We definitely found they had needs. Far greater needs than we expected them to have.”

In navigating and negotiating services, the TCNs were mindful not to “step on toes” of individuals and organizations providing similar services. They felt the need to be firm that they were not trying to replicate, duplicate, or replace existing services. They described “selling” the TCN program as a complementary service within the community. This involved ensuring a level of understanding about the TCN program both externally and internally to the hospital site.

Primary care practices were of significant importance n the TCN program. The TCNs needed to ensure proper communication and engagement with the primary care practices and providers. One participant explained, “I would try at least once a month to go to physician offices or practices to ensure they knew who I was, what I was there for, and how I could help them.”

Discomfort With the Role Transition

All participants reported varying levels of discomfort during their role transition. Specifically, the program development was uncomfortable because there were no “road maps” about how things should be done. The participants reported that most of the transitional care models were urban focused and required a steady workforce to provide support. Participants described the program development in the following ways: “We were building the airplane as it is flying” and “We knew we needed to do it differently to make it work in our community.”

The participants shared personal discomfort. The position had many unknowns and required perseverance and commitment to step outside of one's comfort zones. The participants acknowledged that change was not easy. One participant stated, “The biggest challenge, I think, was going outside the walls of the hospital. For 40 years I was a hospital nurse and very comfortable as a hospital nurse.”

Participants shared that the urgency to pick up patients occasionally rushed along the orientation and onboarding, long travel times, the need to be flexible, the uncertain schedule, the uncertain financial sustainability of the program, and how their old roles “just went away.” All participants expressed concerns about travel times and never “knowing what the day will bring.”

A Level of Altruism and Autonomy

Despite the discomfort, all participants shared examples of positive role transition experiences. Participants shared how the role aligned with their values of altruism and autonomy. The role was perceived as incredibly rewarding, as 1 participant explained: “Working as a TCN was the best role of my life as a nurse. And believe me, in my 45-year career, I've had many roles and worn lots of hats.”

All participants talked about a level of altruism with the role. Many wondered what patients and families would do without them. They were grateful for recognition, especially “recognition for a program that was initiated by nurses trying to solve a problem.” All participants described feeling as if they were making a difference, as one explained: “Using the TCN program to provide the right kind of care in a low cost setting, by keeping quality high…is certainly something we value greatly, it is the future of nursing.” The participants felt appreciated by patients, family, the organization, and the community.

Recommendations for Improving the TCN Role

The participants provided recommendations for improving and sustaining the TCN role. All participants expressed the need to improve both documentation and data metrics toward improvement and sustainability of the program. Participants explained: “How were we going to prove that we were making a difference?” and “data will drive whether we can continue to show the value of the program and that has been difficult.”

Additional recommendations for improving the TCN role included ensuring a supportive organization and leadership. The participants felt extremely supported by the organization and leadership. The participants expressed the need for a “deeper dive” into whether CNSs should continue to staff the TCN positions in the future. One participant explained, “I am a strong believer that a master's-prepared nurse is what is needed in this role. Experience is something you cannot learn without time.” All participants expressed the need for the role to evolve as healthcare and needs changed.


Our study is one of the 1st to describe the perceptions of nurses moving into transitional care roles. These perceptions are critical for improving and sustaining transitional care programs. Findings of the current study have several implications for the development and implementation of TCN programs. These implications can inform and guide other TCN programs by developing orientation and onboarding standards, transition expectations, and general program developments.

The collaboration among the TCNs in this study helped to build the foundation for the program at the site hospital. Such collaborations may be rare and challenging to replicate in this program with new hires or in other institutions. It remains unclear on whether a new set of TCNs, without the previous years of rapport, will still have the same level of comradery and opportunities for debriefing that the participating TCNs found so valuable. Nevertheless, developing trust among TCNs should be an important component of TCN training programs.11 More research is needed to develop and test trust-building interventions for TCN teams.

Nurses are often the provider of choice to lead TCN programs, and it should not be assumed that they will transition without difficulty.5 Our study found the transition rewarding, but also incredibly challenging for the nurses. These findings align with a study completed by Sherman.11 However, unlike Sherman,11 our participants described the overall experience positively because of support, trust, and comradery. The TCNs described it as going from an expert to novice. An expert to novice transition should be built into a comprehensive orientation that includes reframing and self-reflection.12 Reallocating nurses into the role needs to include training that considers their previous knowledge and learning needs to decrease discomfort. Improved satisfaction with the transition may contribute to enhanced effectiveness and better retention.

Hospital discharges are complex and involve multiple members of a care team without always considering what is most important to the patient and family.13 Allen et al14 also describe the need for patients and caregivers to be more involved in their care and take greater responsibility in care needs. This is especially true for hospital to community transitions. Transitioning patients using patient-centered approaches before hospital discharge and admittance to a TCN program can provide a proactive approach to transition needs. Addressing transitional needs proactively and as a team may improve TCNs' experience with TCN programs.

Transitional care programs are meant to be an interprofessional collaboration and complementary service.5 Transitional care is not defined by a beginning and end point. Therefore, the subjective interpretation of not knowing when transitional care begins and ends results in variation and confusion.14 Additional research is needed to determine whether the challenge is on a systems level (lack of community resources for an effective interprofessional collaboration) or within the TCN role itself (functioning as a true complementary service or perhaps functioning, unintentionally, in a silo). This is important because it highlights the need to understand community resource gaps from a hospital perspective. Hospitals and community partners need to collaborate to identify and address gaps to create a community partnership toward effective care transitions


Although this is 1 of few studies to describe perceptions of CNSs transitioning into a TCN role, there are limitations. The participants were recruited from a single transitional care program specific to the site hospital. Furthermore, the study only collected data from CNSs making the transition. Therefore, findings may not be generalizable to other program, hospitals, and roles. Future studies replicating this study through multiple sites and programs would be useful for a broader range of perspectives.


Healthcare reform provides opportunities for nurses to drive innovation and improve patient care, especially for patients transitioning across services. Implementation of TCN programs often involves using hospital-based nurses to fill community-based roles. Because these transitions can be challenging for nurses and threaten implementation and sustainability of TCN programs, it is essential for nursing leaders to understand and address the perceptions of nurses regarding role transitions. Transitional care nurse programs can significantly improve the care and well-being of patients transitioning from hospital to home; however, gaps in community resources and in training may threaten the positive impact and sustainability of these programs.


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