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An Educational Tool for Promoting Transitional Health Care Planning by Nurses From the Hospital to the Community

Jones, Sharon Caldwell; Waynick-Rogers, Pamela

Author Information
Nursing Education Perspectives: May/June 2020 - Volume 41 - Issue 3 - p 190-192
doi: 10.1097/01.NEP.0000000000000463


Transitional care planning is essential in current health care to reduce costs, improve patient outcomes, and enhance the health care system overall (Burton, 2012; Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015; Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011; Snow et al., 2009; The Joint Commission, 2012). The roles of health care providers in the patient transition process need to be recognized and promoted (Hirschman et al., 2015; Morrison, Palumbo, & Rambur, 2016). The Institute of Medicine (2001) identified the core needs for the health care system as safe, effective, patient centered, timely, efficient, and equitable. Yet, as the health care system has grown in scope and complexity, these aims are not always reached, especially when a patient transitions from an inpatient setting to another care setting, such as home.

Nursing organizations support the active role of nurses to facilitate effective transitions from inpatient to outpatient settings. A recent American Nurses Association (ANA) position statement asserts that care coordination should be “infused throughout registered nurses’ curriculum” (ANA, 2012a, p. 7), and the ANA White Paper on Care Coordination echoes the importance of including care coordination in RN education (ANA, 2012b). The AACN Essentials for Baccalaureate Education for Professional Nursing Practice (2008) state that nursing education should prepare the graduate to “facilitate patient centered transitions of care” (p.31) ultimately to promote safe care and that clinical practice must expose students to “accelerated care transitions” (p.34). The Quality and Safety Education for Nurses competencies (Cronenwett et al., 2007) address transitional care planning to improve the quality and safety of the health care system. For patient-centered care competency, nurses must “integrate understanding of multiple dimensions of patient centered care,” including “coordination and integration of care” (p. 123). For the teamwork and collaboration competency, nurses must “follow communication practices that minimize risks associated with handoffs among providers and across transitions of care” (p. 125).


Educators have the responsibility to include transitional care systems, processes, and essential transitional care components in the nursing curriculum (Fortier et al., 2015; Morrison et al., 2016). The Transitional Nursing History (TNH) provides nursing students with a template for assessing potential transitional health care needs of patients as they move from one care setting to another and guides student assessment and prioritization of patient/family/caregiver needs during transitional points of care (see Supplemental Digital Content, available at, for the tool with sample questions). With a national focus on health promotion and prevention of and decreased length of acute care admissions, community health clinical sites are relevant and appropriate sites for students to identify potential patient needs, as well as resources and barriers of care for patients and their families in the community. The TNH tool facilitates the integration of inpatient and community health clinical experiences for students. For the assignment, care transitions were defined as “a continuous process in which a patient’s care shifts from being provided in one setting of care to another” (Naylor et al., 2011, p. 1).

Healthy People 2020 Determinants of Health (DoH) (US Department of Health and Human Services, 2017) provided the framework for the transition planning tool components. Students use the tool to record patient diagnoses, medications, potential barriers, and necessary resources. The tool also provides a template to identify the educational needs of the patient and/or family. Based on the TNH, students develop a transition plan for a selected patient from the hospital to the community that supports patient and/or family empowerment.

Inpatient clinical forms for review include an information and hospitalization summary; a primary pathophysiology summary; definitions of comorbidities; synthesis of health behavior status by primary, secondary, and tertiary levels; medications; and laboratory values. An additional area highlights the community health component, requiring students to assess the relevant issues of transition planning, abnormal laboratory values, and medications.

TNH Implementation

During implementation, transitional care planning questions are part of the inpatient plan of care form used in clinical rotations. Students are allowed time in the inpatient setting for further chart review and additional questions in the patient/family/caregiver assessment. Students identify the highest priority diagnosis for their chosen patient in each DoH category: social (social and physical factors), health services, and individual behavior, as well as a patient-centered goal and expected outcome.

Based on patient/family teaching needs for nonpharmacological interventions, students develop evidence-based nursing interventions. They must identify current health care policy or guidelines that support or affect interventions. Finally, students describe evaluation parameters for measurable outcomes of a successful patient transition from the perspective of the nursing case manager or community health nurse.

Students present the TNH and plan of care to their community health clinical groups using a concept map format. Visualization of key inpatient-community linkages, interrelated issues for the patient and his or her family, DoH connections, resources, barriers, and potential health outcomes are part of the required presentation. Students ask questions and share thoughts regarding additional interventions or resources with community health clinical faculty acting as presentation facilitators.

Coordination and Collaborative Processes

Implementation of the tool and successful student learning experiences require coordination and collaboration between inpatient clinical and community health faculty with the support of the program director. Faculty in each setting work collaboratively to enhance the learning experience in the seamless progression of the assignment. As inpatient and community health clinical faculty share perspectives, the result is a common interest for student learning.

Initial concerns included lost in-hospital clinical time and coordination issues among faculty. Time to complete the tool was not a factor, as extra time was allotted for completion of the tool. As faculty shared experiences, several inpatient clinical faculty noted enhanced student awareness and active discussions regarding transitional care planning. Community health clinical faculty also identified greater awareness by students of the importance of planning for transitions, regardless of site. Enhanced faculty collaboration resulted from the assignment.

Student Outcomes

Students reported a better appreciation of being knowledgeable about community resources, access, barriers, and the significance of assessment in determining patient understanding and ability to navigate the health care system. Students also integrated the vital nature of addressing DoH categories when assessing patient needs, resources, and barriers to promote a positive transitional process. Students also had to address patient and family medication education needs for transitional care planning and commented that this “made them think” about ramifications for their actual patients and families. Methods for medication prescription fulfillment, educational needs for accurate medication adherence and dosing, and potential safety risks of abnormal laboratory values had new meaning when applied to the transitional care planning experience by students.

Finally, the concept map application for student presentations promoted active learning and made the plan of care information more meaningful with DoH implications. Students reported being actively involved in the presentations, as presenters and team members, and learning “on the spot,” especially when other interventions and ideas applicable to each patient and his or her family/caregiver were provided by the group. Faculty members facilitated the group learning process.


Because the TNH assignment spans courses and clinical groups, faculty collaboration and support are critical for implementation. There must be support from the program director and course coordinators, and integration of learning experiences between the inpatient and community clinical setting is required.

A main objective of this assignment was to promote student understanding of the interconnectedness of the DoH categories and their impact on the health of individual patients, families, and communities. Implementation of a TNH tool into the nursing curricula facilitates experiential learning for prelicensure students to understand the role of nurses in promoting successful transitions. It is essential in the changing health care environment that nursing students are given tools to support successful transitions they can use in clinical practice. Future research is needed to assess the effectiveness of actual transitional care tools, especially related to communication, interprofessional practice, patient efficacy, and health outcomes.


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Community; Determinants of Health; Educational Tool; Nursing Education; Transitional Health Care

Supplemental Digital Content

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