• Consider the nurse leader’s role in achieving the IHI Quadruple Aim for this transition of care. (Hint: Draw from resources on systems thinking and nurse leaders’ ability to influence innovation and change.)

Assignment (5–6 pages, not including title and reference page):

Write a paper in which you address the following:

• Identity your selected example of a transition of care.
• Describe the key stakeholders that might be involved in this transition of care and the leadership strategies you would use to engage and influence them.
• Explain how you, as a nurse leader along with your healthcare team, would apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework in order to improve it. Explain the fourth aim and strategy you would use and why.
• Explain how systems thinking would inform your improvement plan for the specific transition of care you selected.

Running head: ANNOTATED BIBLIOGRAPHY 1

ANNOTATED BIBLIOGRAPHY 6

Annotated Bibliography

Institution

Course Tittle

Date

Hendrix, C., Tepfer, S., Forest, S., Ziegler, K., Fox, V., Stein, J., . . . Colon‐Emeric, C. (2013). Transitional care partners: A hospital‐to‐home support for older adults and their caregivers.Journal of the American Association of Nurse Practitioners, 25(8), 407-414. doi:10.1111/j.1745-7599.2012.00803.x

The authors of this article conducted a study describing the transitional care (TLC) Partners Program at a Durham VA medical center in Durham, North Carolina. The study aimed to establish the generalizability of nurse-led transitional care programs to VA patients with chronic illnesses and social challenges. They were also describing the adaptation and implementation of evidence-based transitional care programs to a unique system that may inform other healthcare providers and administrators wishing to offer such services. Veterans aged 60 years or above, who live within 35 miles from the Durham VAMC, will be discharged home, are not enrolled in hospice and will benefit from having close medical surveillance after hospital discharge, was the population studied. The authors show how nurse-led interprofessional care model can be adapted to the needs of the healthcare system, how they can be monitored to evaluate reach, effectiveness, and fidelity to the core components of proved care models.

Kokonya, A., & Fitzsimons, V. (2018). Transition to long-term care: Preparing older adults and their families. MedSurg Nursing, 27(3), 143-148.

The authors conducted a systematic review on long term care, to identify and explore factors that involved preparing older adults and their families for the transition from home to acute care to LTC facilities. The authors also conducted quantitative research, semi-structured, in-depth, and face-to-face interviews. Transitioning to long-term care facilities can be a devastating life event for older adults, and older adults must be prepared for the move to LTC.

Transition and relocation to an LTC facility can be a challenge to older adults and their families, which can lead to emotional distress. Factors that can interfere with decision making for the unplanned move are lack of social support and poor coping abilities. The family has a critical role to play in the transition of care to home. The authors stated that the nurse has a shared responsibility to establish a good relationship, lead coordination to patient care, and assist the patient in transitioning from one setting to another. However, nurses need to be well prepared in the field of geriatrics and gerontology.

Hung, D., Truong, Q., Yakir, M., & Nicosia, F. (2018). Hospital-community partnerships to aid transitions for older adults: Applying the care transitions framework. Journal of Nursing Care Quality, 33(3), 221-228. doi:10.1097/NCQ.0000000000000294

The researchers of this article explores the implementation and hospital-wide scaling of a community-based transitional care program to reduce readmission among adults 65 years and older. The data gathered was from interviews with key individuals responsible for implementing the program in all units of the hospital in partnership with community-based organizations. The article focuses on the implementation and delivery of transitional care for older adults and is based on analysis using the Care Transition Framework (CTF). There is a need for adequate planning, engagement, and resources at each stage of the implementation process. Due to the changes in healthcare, programs that assist older adults in the transition of care are becoming more prevalent because of an aging population and an increasing emphasis on patient-centered care. The authors highlighted that implementing these programs will facilitate hospital-to-home transitions as the demands for services expands.

Dierckx de Casterlé, B., Willemse, A. N., Verschueren, M., &Milisen, K. (2008). Impact of clinical leadership development on the clinical leader, nursing team, and caregiving process: a case study. Journal of Nursing Management, 16(6), 753-763.

The research of this article explores the dynamics related to the leadership development plan and the impact of the nursing leader, the clinical team, and the process of giving care to the needy. The research was carried out in an academic hospital where a clinical leadership development project was implemented successfully. Data was collected through interviews and focus groups and observations. The data were organized according to the impact of the nurse leader, the team, and the caregiving procedure. According to the outcomes of the research, leadership is an ongoing process and interactive between the leader and the nursing team. The lead nurse was effective in sections of communication, performance, and awareness—the nursing team gained from the nursing leadership through effective communication, accountability, and empowerment. The results of the study give more insight into the role of the nursing leader in the caregiving process. Nurse leadership improves the output and accountability of the nursing team and contributes to giving the patient the most required care as they transition to other care facilities or even when being discharged. The research study is relevant to my paper because it shows the growing need and importance of transformational leadership in the nursing section and the need to invest in leadership development. Improved nurse leadership will influence transitional care through the nursing team to the patients.

Rokstad, A. M. M., Vatne, S., Engedal, K., &Selbæk, G. (2015). The role of leadership in the implementation of person-centered care using Dementia Care Mapping: a study in three nursing homes. Journal of nursing management, 23(1), 15-26.

The researchers of this study give a thorough examination of the role of leadership in the implementation of person-centered care. The study was undertaken in three nursing homes and used Dementia Care Mapping (DCM). The study used descriptive design in the three nursing homes, seven nurse leaders and eighteen staff members were involved in the interviews. The outcomes from all three nursing homes influenced the extent of Dementia Care Mapping resulted in the successful implementation of person‐centered care. The article is essential for my paper because it provides useful information about the influence of leadership in the implementation of care in nursing homes. It also shows why the leaders should be active in their leadership and empower the nurse so that they can provide good care. Additionally, the results of the research study indicate that leadership styles by the nurse leaders are related to the job satisfaction of the employees.

References

Dierckx de Casterlé, B., Willemse, A. N., Verschueren, M., &Milisen, K. (2008). Impact of clinical leadership development on the clinical leader, nursing team and care‐giving process: a case study. Journal of Nursing Management, 16(6), 753-763.

Hendrix, C., Tepfer, S., Forest, S., Ziegler, K., Fox, V., Stein, J., . . . Colon‐Emeric, C. (2013). Transitional care partners: A hospital‐to‐home support for older adults and their caregivers.Journal of the American Association of Nurse Practitioners, 25(8), 407-414. doi:10.1111/j.1745-7599.2012.00803.x
Hung, D., Truong, Q., Yakir, M., & Nicosia, F. (2018). Hospital-community partnerships to aid transitions for older adults: Applying the care transitions framework. Journal of Nursing Care Quality, 33(3), 221-228. doi:10.1097/NCQ.0000000000000294
Kokonya, A., & Fitzsimons, V. (2018). Transition to long-term care: Preparing older adults and their families. MedSurg Nursing, 27(3), 143-148.

Rokstad, A. M. M., Vatne, S., Engedal, K., &Selbæk, G. (2015). The role of leadership in the implementation of person-centered care using Dementia Care Mapping: a study in three nursing homes. Journal of nursing management, 23(1), 15-26.