Health care settings function in a well collaborative manner where multidisciplinary work environment exists. In a complex care situation, such as transition care of patients, the role of nurse care professionals was believed to be vital in coordinating the care. For instance, in geriatric settings, it is these professionals who can take up the complex tasks to enable the elderly individuals in transition from the care center to their residence seek suitable care and therapy (Cortes, Wexler & Fitzpatrick, 2004). So, there is a growing research interest on how these nurses utilize their potential in administering the care quality for these patient groups. Transition nurse can better play role as leaders in the broad care system in a given community. The duties specific to these nurses are multifaceted, complex, involve expenditure, and personnel management and routine care of patient in transition from the care center to the residence. However, there seems to be a problem that interrupts this area of transition care.
The problem is deficiency of patient data or information when a particular patient encounters a transfer from one care center to the other (Cortes, Wexler & Fitzpatrick, 2004). Such information defect continues to exist and paralyze the efficient care plan of the elderly individuals in a timely manner. More probably, the care of these older people during a transfer to the residence or nursing home could promote increase disturbances in their care continuum. Apart from this, any modification to the environment of hospital could also interfere and continue for extended time period (Cortes, Wexler & Fitzpatrick, 2004). This mode of consistency in problems or adjustment difficulties could contribute to aggravation of a given disease processes and finally readmission to the hospitals. In fact, evidence mentions that older people who are hospital discharged encounter increased rates of readmission.
In some developed nations such as US and UK, the increase in the rates of elderly patient hospital admissions is increasing (Courtney et al., 2011).
Nurses appear to fail in recognizing this trend in the elderly care system.
Even though, the older patient is more likely to suffer from a communication breakdown, ever staff member including the nurses involved in the care of the resident are badly affected. Hence, the existence of huge gaps in the elderly care and their care providers at the time of vital transitions could lead to complicated events, poor care satisfaction, unmet needs, and increased rates of rehospitalization (Naylor & Keating, 2008).
The purpose of this work is to highlight the problems encountered by the nurses in the transitional care of elderly and come up with feasible intervention to improve the transition care, reduce the adverse events encountered by these elderly patients and enhance their quality of life (QOL).
References
Cortes, T.A., Wexler, S. & Fitzpatrick, J.J. (2004). The transition of elderly patients between
hospitals and nursing homes. Improving nurse-to-nurse communication. J Gerontol
Nurs,30(6),10-5(quiz 52-3). Abstract.
Courtney, M.D., Edwards, H.E., Chang, A.M., Parker, A.W., Finlayson, K. & Hamilton, K.
(2011). A randomised controlled trial to prevent hospital readmissions and loss of functional
ability in high risk older adults: a study protocol. BMC Health Serv Res,11,202.
Naylor, M. & Keating, S.A.(2008). Transitional care. Am J Nurs,108(9 Suppl),58-63(quiz 63).
