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 Attached is PP with instructions and all phases for corrections

Phase Five Research

Phase V- Research Paper

• Throughout the semester we have been working at completing papers and different
phases remember that you started out with Phase One, then you begin working on
Phase Two, then Phase Three, Phase Four and now for Phase Five of your research
paper, this is where it all comes together.

• Before assembling your final project, please review your previous issues to ensure
that prior errors are corrected, or any feedback is addressed.

• Very Important Class – please make sure that your paper is completed in Microsoft
Word, do not use pdf or any other format, it cannot be accepted for grading.

Important Items for Review

• Aesthetics – How does my paper look?
• Am I submitting scholarly work?
• Is it formatted properly?
• Is the paper free of grammatical errors?
• Did I follow APA 7th edition guidelines?
• Content – is my paper organized?
• Do the prior sections flow properly?
• Are the titles present? Did I use proper heading levels?
• Did I check for plagiarism? Did I keep my similarity index < 20%?

Phase V – Research Paper

• The final submission is the combination of the other four phases into one paper.
• You will combine Phase I, Phase II, Phase III, and Phase IV to make Phase V.
• You are responsible for editing and formatting your paper so that your paper will

flow for the reader.
• This paper will need to be corrected with all the feedback provided from previous

• Include conclusion and learning experiences from the essentials and from the class.
• Do not forget to document limitations and implications for future


Review of Phase One

• The purpose of this project is for the student to complete all the different steps
necessary to implement a nursing research project.

• This project will be subdivided into 4 different papers that will be submitted
throughout the entire semester.

• The final paper will be the combination of the four areas.
• Always remember to review the grading rubric on your syllabus before completing

any assignment.
• Your grading rubric can be located within your Blackboard Submission tab

for the assignment

Review of Phase One

• Phase 1 is the planning stage of a research project; students are to prepare a 4-5-page paper identifying a specific topic that you
would like to investigate and relates to transitional nursing. You will provide a brief introduction to the situation by utilizing
published nursing research articles to support your statement. This paper will also include

• 1- Introduction to the Problem
• 2- Clearly Identify the Problem
• 3- Significance of the problem to Nursing
• 4- Purpose of the research (what do you seek to accomplish)
• 5- Research questions (this will guide your research)
• 6- Master’s Essentials that aligned with your topic

Review of Phase Two- Design

• You will continue with your research topic.
• In this paper will perform a brief literature review on the topic.
• Will need at least 5 support articles (scholarly research).
• Provide the desired methodology for the project.
• Paper will be approximately 5-6 pages.

• 1- Brief literature review
• 2- Methodology and design of the study (Be as detailed as possible – qualitative/quantitative)
• 3- Sampling methodology
• 4- Necessary tools
• 5- Any algorithms or flow maps created

Review of Phase Three- Implementation

• Phase 3 of the research project is the implementation phase.
• The implementation phase will be written in the future state as we will not

be implementing the actual project.
• This phase focuses on providing steps by steps instructions on how the

program will be implemented.
• A table describing the time frame of the project, if there is any budget that

needs to be considered, and any resources or statistical tools required.
• The length of this paper should be around 5-6 pages.

Review of Phase Four- Results

• Phase 4 is all about results.
• This part of the paper will be based on the hypothetical analysis.
• Meaning since we will not be implementing the process, the results described will be

based on whatever the students would like the research results to be.
• You will need to provide results for all the statistical tools mentioned and provide

descriptive data (demographics of the population, different descriptive data points,

• Make sure to also include research limitations to improve for future studies.
• Approximately 6 pages.

Phase Five- All Phases Combined

• The final submission is the combination of the other four phases into one paper.
• You will combine Phase I, Phase II, Phase III, and Phase IV to make Phase V.
• You are responsible for editing and formatting your paper so that your paper will

flow for the reader.
• This paper will need to be corrected with all the feedback provided from previous

• Include conclusion and learning experiences from the essentials and from the class.
• Do not forget to document limitations and implications for future


Final Thoughts

• Please ensure that all phases are present in your document.
• Review your grading rubric that is within your syllabus.
• Make sure that your in text citations and references are present.
• Ensure that you strive to keep your plagiarism score at 20% or below.
• Although many components of this assignment were hypothetical – think about the

seriousness of research and how it impacts nursing practice at all levels of our discipline.

• Begin to ensure that research becomes a part of your nursing practice.
• Thank you for a job well done and best wishes unto all.

  • Phase Five Research Paper
  • Phase V- Research Paper
  • Important Items for Review
  • Phase V – Research Paper
  • Review of Phase One
  • Review of Phase One
  • Review of Phase Two- Design
  • Review of Phase Three- Implementation
  • Review of Phase Four- Results
  • Phase Five- All Phases Combined
  • Final Thoughts


Phase 3



Phase 3: Implementation

The section will discuss the steps of implementation and how the project will be completed.

The steps include data sampling, participant selection, data gathering, and analysis. The thesis of

study will be focused throughout the research project, and issues in the transition from hospital to

home and re-admissions will be kept in mind. The details of the implementation process are as



Choosing Participants

The sampling process is an important step in the implementation because it demonstrates

the researcher’s knowledge of how much he has a grasp on his knowledge and how he will

continue the further research. The success of research depends on the sampling process because it

is seen that inappropriate sampling gives inappropriate outcomes.

The researcher needs to be careful in this process, and it helps him make sound decisions

regarding the researcher. The sampling technique will help the researcher to make a careful

decision despite stratified sampling. The sampling techniques and methods depend on the subjects

under investigation because the researcher knows what subjects are aligned with the research or

what are not (Chen, 2021).

The first step will focus on the participants who have been through the re-admissions in the

hospitals. The nurses will also be involved in the research, and the data will be collected from

those who have suffered from severe issues and got re-admission. The patients who never faced the

issues of re-admission or who do not have such concepts will not be considered for the study.

Moreover, it will be seen that the participants should understand the English language, and they

should provide honest reviews.

Nora Hernandez-Pupo
this is your inclusion/exclusion criteria
Nora Hernandez-Pupo
so what king of sampling technique will you be using?

n non-probability sampling, the sample is selected based on non-random criteria, and not every member of the population has a chance of being included. Common non-probability sampling methods include convenience sampling, voluntary response sampling, purposive sampling, snowball sampling, and quota sampling.

Nora Hernandez-Pupo


The research will be carried out with 50 participants, and some of them will be nurses.

Others will be the patients who have the experience of re-admissions in the hospital. Moreover, the

situation of COVID-19 will be kept in mind because it may affect the sampling.

Nurses working with the re-admissions of patients will be preferred because the

participants should have sound knowledge about the reasons and issues in this context. There are

different patients, and at the same time, there are nurses in different specialized areas, so it will be

important for the researcher to choose the nurses specialized in the context under study.

They should have vast experience working with patients who suffer from the issues of re-

admissions. The participants will be contacted in their free time because the nurses are usually

exhausted because of their busy routine, and their duties are long hours. Moreover, the patients are

also exhausted because of their illness, so all these factors will be considered (Maki, 2021).

The research is usually done physically because it is easy for the researcher and the

participants to interact. The situation at present is not suitable for physical interaction so that the

research will be conducted in alternative ways.

If physical interaction is not possible, the online exchange will be managed. The research is

difficult to conduct in the coronavirus so that the planning will be done accordingly, and the

participants will be informed of the protocols.

The hospital administration will be contacted, and they will be informed of the research.

They will be told all the research protocols, including the nurses and the patients in the research.

There will be 50 participants, and they will be contacted in their free time, and interviews will be

taken by telephone (Wong, 2021).

Nora Hernandez-Pupo
this doesn’t really fit here- you have to have IRB and informed consent- which you do further down- I would delete this section
Nora Hernandez-Pupo
completed face to face…
Nora Hernandez-Pupo
Nora Hernandez-Pupo
I am little confused- you will have two groups of participants: Patients and nurses- ??
You need to be clear what you are looking at with each participant group-
It is unfocused- revisit and clarify for final submissions
Nora Hernandez-Pupo
or you put it with the consent part


Ethical Standards

The researcher needs to follow the ethical standards and protocols, and they are discussed

as follows.


There are certain protocols in the research, and it is the first rule that they should be

informed of the research details. They should know the purpose of the research, and their volunteer

response and consent are necessary. The researcher must make the participants understand why

they are contacted and the expected outcomes of the researcher. Their roles and responsibility in

the research will be defined, and they will be informed about how and when they will be contacted

(Valliant, 2018).

They are given a choice to decide to participate in the research. They should be told all the

possible risks of the study. The researcher is responsible for disclosing the information to the

participants because if they are not informed of the procedures, their consent will not be ethical.

Moreover, they are told there will be no harm, and their private information will not be disclosed.

It is important to remember that the participants should be respected, their dignity should be

maintained, and there should be no threats. The current study will follow all the protocols and

ethical standards of the research.


The privacy and confidentiality of participants and institutions are the important concerns

of the study. The research will ensure that the research will be conducted with complete privacy

and no information will be disclosed. In the context of confidentiality, the researcher will assure

that the personal details of participants will be kept private and will not be used for publishing

purposes. Once the information is collected, all the details will be hidden, and the unknown codes

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you have to include IRB approval



will be given for identification. Due to coronavirus, the data will be collected through telephonic

interviews. The telephone recordings will not be accessible to anyone, and the dignity of

participants will be maintained. After completing the study, all the records will be discarded

carefully so no one can access them.


Moving on, autonomy is another important parameter in the context of research. All the

institutions and participants will be asked to ensure their volunteer consent in written form. They

should ensure that they are part of the research with no pressure and with their will. They will

choose to stop responding and withdraw from the study with their will (Oh, 2021).


It has already been assured that the participants will be told of all the possible risks in the

research. Nursing is a sacred profession, ensuring that the research will not affect their duties and

profession. They will be contacted in their free time, and they will be given proper time to respond.

All the patients and their families will be respected, and their dignity will be maintained throughout

the research.

Data Analysis

Data analysis is an extremely important process, and whole research success is based on it.

If the researcher uses the appropriate research tools, the results will be analyzed accurately, and the

desired outcomes will be achieved. The basic statistical tools will be used in the research. The

charts and flowcharts will be used for the data analysis, and the results will be interrupted in detail

(McHugh, 2021).

Nora Hernandez-Pupo
you have to list what method of data analysis will be utilized? what tools exactly
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grammar – on
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the conversation is transcribed for review and data analysis- member checking is also completed- you have to list it



The researcher will interrupt the results and inform the hospital management of the gaps

and the common reasons for the re-admissions of patients. So, the nurses will be given training


There are two important steps involved in the implementation: the timeline schedule and

budget planning.

Table 1

Gantt Chart

Week 1 2 3 4 5 6 7 8

Sample Collection

Ethical Standards Training

Data Collection

Data Analysis

Training for Data analysis

Report Finalization


The budget planning has been shown in the table below. The researcher has to decide the

budget as early as possible because he has to arrange the resources of funds. The major costs will

be the training of nurses after the declaration of results. The advertisement is also necessary for

participant selection. The details of the budget are shown as follows.


Table 2


Item Cost ($)

Promotion and advertisement 400

Training 1500

Survey expenditure 1500

Analyzing results 2000

Training for research 8,000

Total 13,400



Chen, J., Wijesundara, J. G., Patterson, A., Cutrona, S. L., Aiello, S., McManus, D. D., … &

Houston, T. K. (2021). Facilitators and barriers to post-discharge pain assessment and

triage: a qualitative study of nurses’ and patients’ perspectives. BMC Health Services

Research, 21(1), 1-15. Doi:https://doi.org/10.1186/s12913-021-07031-w.

Maki, S., Nagai, K., Ando, S., & Tamakoshi, K. (2021). Structure and predictors of in-hospital

nursing care leading to a reduction in early readmission among patients with schizophrenia

in Japan: A cross-sectional study. PLoS One, 16(4), e0250771. Doi:


McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021).

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, re-

admissions, and length of stay: a prospective study in a panel of hospitals. The Lancet,

397(10288), 1905-1913. Doi: 10.1016/S0140-6736(21)00768-6.

Oh, E. G., Lee, H. J., Yang, Y. L., & Kim, Y. M. (2021). Effectiveness of discharge education with

the teach-back method on 30-day re-admission: a systematic review. Journal of patient

safety, 17(4), 305-310. Doi: 10.1097/PTS.0000000000000596.

Valliant, R., Dever, J. A., & Kreuter, F. (2018). Practical tools for designing and weighting survey

samples. Doi: 10.1007/978-1-4614-6449-5.

Wong, C. H., Cheung, W. K., Zhong, C. C., Yeoh, E. K., Hung, C. T., Yip, B. H., … & Chung, V.

C. (2021). Effectiveness of nurse-led peri-discharge interventions for reducing 30-day

hospital re-admissions: A network meta-analysis. International Journal of Nursing Studies,

103904. Doi: 10.1016/j.ijnurstu.2021.103904.

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6 references


  • Phase 3: Implementation
    • Steps
    • Budget


Phase -4 Results


As part of this research, the primary goal is to give an explanation and the correct set of

examination of the correlations between early provider follow-up and the nursing care coordination

or intensity management kind of intensity. Prior to presenting a series of comparisons between

groups for readmission and Employees provident fund (EPF) within 14 days, sample

characteristics will be shown in this assignment. The correlations between the variables will also

be given in a bivariate form. Finally, each of the study goals will be successfully handled by the

results of the statistical analysis (Allen et al., 2018).


During the following research, the critical upstream components that affect the provision of

transitional care for the specified senior group were discovered. For example, the identified

providers and nurses may successfully adjust transitional style of care for senior individuals to the

recognized population aspects like cardiovascular illness load as well as the downstream elements

like the neighborhood disadvantages among others Nursing research should continue to expand on

this sort of individual-level and even population-level interventions in order to achieve better

results for patients (Rasmussen et al., 2021).

Sample Characteristics

Following the extraction of instances that met the inclusion criteria, exclusions, and data

cleaning, a final study sample of 1280 cases was successfully accomplished. Mean age was 79.5,

with 50.7 percent of participants being female and 25.9 percent non-white. A total of 94.9 percent

of the study participants were enrolled in the well-known Medicare program. A total of 3.6 percent

of the population was covered by private insurance. The average length of stay in the hospital was

five days, and roughly 31.8 percent of patients were discharged with recognized home treatment

(DelBoccio et al., 2017).

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extraction – like pulling out of teeth ???
Nora Hernandez-Pupo
???? no idea what you trying to say–
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Nora Hernandez-Pupo
which specified senior group- you have to state what you are looking for – what your topic is
and what are you trying to convene by saying ‘upstream’
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Nora Hernandez-Pupo
a little confused as to what you are trying to say- read it out load to someone and see if they understand it… you need to rethink this sentence


According to the recognized health-related system area, the principal homes of the subject

were effectively distributed throughout the defined west which was 34.5 percent, the main which

made up 18.4 percent, and the east which made up 47.1% areas. This included the six most

important counties in the state. According to the research, 92.0 percent of participants in the

identified study were found to live in urban areas, and 20.2 percent of them were found to live in

the most impoverished districts. Thirteen percent of the final sample was found to have a 30-day

readmission rate of 13 percent (Allen et al., 2018).

In the seven days after the study began, 34.1 percent of individuals had EPF, and 60.1

percent of those subjects had EPF within the 14 days. There were 46.3 percent of the identified

sample that had at least one Care Coordination and Transition Management (CCTM) interaction

within 30 days after discharge, and 38.8 percent had at least one CCTM contact during the first

three days following discharge, based on the level of the CCTM intensity. The following tables

summarize the patient characteristics by readmission status and EPF throughout the 14-day period

(Menezes et al., 2019).

Table 1

Patient Characteristics and 30-Day Readmission Status



N=1114 (87.0%)

N=166 (13.0%)


Age* 79 73, 94 80 73,94 78 71,93 .031

Sex .718

Female 649 50.7% 567 50.9% 82 49.4%

Male 631 49.3% 547 49.1% 84 50.6%

Race .059

white 948 74.1% 835 75.0% 113 68.1%

non-white 332 25.9% 279 25.0% 53 31.9%

Length of stay* 4 3,10 4 3,10 4 3,14 .069

Nora Hernandez-Pupo
very nice table


Discharge disposition .565

Home 873 68.2% 763 68.5% 110 66.3%

Home health 407 31.8% 351 31.5% 56 33.7%

Comorbidity Index* 37 27,62 36 26,62 44 32,65 <.001

Neighborhood .029

least disadvantaged 1022 79.8% 900 80.8% 122 73.5%

most disadvantaged 258 20.2% 214 19.2% 44 26.5%

Comparison of Groups

Note that six factors, including age, comorbidity index, neighborhood disadvantage, EPF

identification within 7 and 14 days, and two CCTM contacts, were associated with the question of

readmission. More than a third of the patients classified as being at high risk of being readmitted

were younger, had more comorbidities, and resided in a less affluent area, compared to those who

did not have readmission. According to the analysis, most of the patients with detected

readmissions had two or less CCTM interactions and fewer provider follow-ups in the indicated 7

or 14 days than patients with no readmissions. CCTM intensity was not associated with

readmissions, as previously stated (Weeks et al., 2018).

Table 2

Patient Characteristics and Early Provider Follow-Up Within 14 Days

Early Provider Follow-up

No Yes p-value

Age* 80 72, 87 79 73, 86 .159

Sex <.001

Female 293 57.3% 356 46.3%

Male 218 42.7% 413 53.7%

Race <.001

white 344 67.3% 604 78.5%

non-white 167 32.7% 165 21.5%

Length of stay* 4 3, 6 4 2, 6 .030

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Discharge disposition .008

Home 327 64.0% 546 71.0%

Home health 184 36.0% 223 29.0%

Comorbidity Index* 38 27, 51 36 26, 47 .027

Neighborhood <.001

least disadvantaged 377 73.8% 645 83.9%

most disadvantaged 134 26.2% 124 16.1%

30-day readmission 80 15.7% 86 11.2% .020

CCTM Intensity* 0 0, 1 1 0, 2 <.001

CCTM contact completed

within 3 days 150 29.4% 346 45.0% <.001

within 30 days 179 35.0% 413 53.7% <.001

Number of CCTM contacts

None 332 65.0% 356 46.3% <.001

1 contact 72 14.1% 199 25.9% <.001

2 contacts 53 10.4% 101 13.1% 0.137

3 contacts 25 4.9% 53 6.9% 0.143

4 contacts 19 3.7% 33 4.3% 0.611

5 contacts 10 2.0% 27 3.5% 0.104

Relationship among the variables

The majority of subjects had bivariate correlations ranging from modest to moderate

between the study’s linked variable and the covariates. The figure below effectively summarizes

the discovered orientations in respect to the observed correlations.

Table 3

Multivariable Analysis of Factors Associated with 30-Day Readmission

Variable B SE Wald df OR 95% CI p-value

EPF within 14 days -.364 .169 4.613 1 .695 .499, .969 .032

CCTM, 2 contacts .511 .227 5.075 1 1.666 1.069, 2.598 .024


Comorbidity Index .023 .006 16.324 1 1.023 1.012, 1.034 <.001

B SE Wald df OR 95 percent CI p-value EPF within 14 days of the 30-Day type of

readmission variable B SE Wald df


A weakness of the identified research was that the identified sample was obtained from a

single health-related system, which might have a negative impact on the external validity of the

recognized context-dependent form of mediation that was found. Because the transitional care type

of activities are unique to this specific kind of health-related system, the found association between

the identified early provider type of follow-up and the nursing type of CCTM may not take place in

the other types of health-related system There was no data to back up these nursing practices, but

they did follow the paradigm of the American Association of Critical Care Nurses (AACN) at the

time (DelBoccio et al., 2017). There may also be issues with accuracy and matching when using

retrospective data in a main study from the identified medical records and billing kind of data in

the identified primary research. In addition, the readmission type of data obtained from the original

research may have certain limitations due to the usefulness of just the recognized health system

administrative data source for the identification of hospital readmissions.


The intricate relationship between Early provider type of follow-up, CCTM intensity,

hospital readmission, and even neighborhood disadvantage has been established. ” Comorbidity

and living in a disadvantaged area were both associated with higher chances of readmission. Prior

to 14 days, patients who had an EPF were 30 percent less likely to be readmitted than patients who

did not have an EPF. The lowered EPF was linked to neighborhood deprivation and comorbidities

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good paragraph
Nora Hernandez-Pupo
good reporting of the results- excellent choice on tables- painte dit all very nice- for final submission you want to just explain the findings and how it related to your study’s objective a little more in depth- it would also be a good idea to add other research studies that have the same findings.


during the course of the 14-day study. Furthermore, CCTM intensity was higher in those with

diagnosed comorbidity, but neighborhood disadvantage was reduced in those with CCTM intensity

(Weeks et al., 2018). A clear link between the early provider type of follow-up and reduced

readmissions among elderly HF sufferers was also found, regardless of their neighborhood

disadvantage. Within 14 days of a patient’s return to the hospital, the intensity of nursing CCTM

had no effect on EPF. Although EPF was positively correlated with CCTM intensity and

effectively decreased by neighborhood disadvantage throughout the 14-day period, EPF was not

connected with CCTM intensity. More CCTM contacts were seen in patients who had early

follow-up visits and resided in areas of low to moderate neighborhood disadvantage (Naylor et al.,




Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2018). User experience and care for

older people transitioning from hospital to home: Patients’ and carers’ perspectives. Health

Expectations, 21(2), 518-527.

DelBoccio, S., Smith, D., Hicks, M., Lowe, P., Graves-Rust, J., Volland, J., & Fryda, S. (2017).

Successes and challenges in patient care transition programming: one hospital’s

journey. OJIN: The Online Journal of Issues in Nursing, 20(3).

Menezes, T. M. D. O., Oliveira, A. L. B. D., Santos, L. B., Freitas, R. A. D., Pedreira, L. C., &

Veras, S. M. C. B. (2019). Hospital transition care for the elderly: an integrative

review. Revista brasileira de enfermagem, 72, 294-301.

Naylor, M. D., Shaid, E. C., McCauley, K., Carpenter, D., Gass, B., Levine, C., … & Williams, M.


TRANSITIONAL CARE. Innovation in aging, 2(Suppl 1), 202.

Rasmussen, L. F., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional

care interventions on hospital readmissions in older medical patients: a systematic

review. BMJ open, 11(1), e040057.

Weeks, L. E., Macdonald, M., Martin-Misener, R., Helwig, M., Bishop, A., Iduye, D. F., &

Moody, E. (2018). The impact of transitional care programs on health services utilization in

community-dwelling older adults: a systematic review. JBI Evidence Synthesis, 16(2), 345-






Introduction to the problem

Transitional nursing is Care provided to patients as they transit from one place to another.

Transition can be within the hospital setting, between care settings, within health states, and

between providers (Warchol et al., 2019). One of the transitions is discharge from the hospital to

home care. Patients are discharged from the hospital before they are completely cured but must be

well off to be able to recover at home. The patients are sent home with treatment packages and

sometimes may require frequent clinical visits by the nursing for care. The care plan during the

transition from hospital to home care includes the treatment goals, the health status of the patient,

treatment preferences and family as well as patient education. Coordination is crucial in this care.

In some cases, these discharge packages are not well elaborated. Miscommunication and

discontinued care may result in adverse effects on the patient. For example, the patient may

experience delayed care, unnecessary clinical visits, and stress to the patient or family, and poor

health outcomes.

Problem statement

The transition of the hospital to home care is done to enable the client to recover at home.

Healthcare professionals discharge clients with strict instructions for the client to continue with

care and recover fast. Due to poor communication and nursing care at home, many patients face

readmission. Readmission is defined as the return to hospitalization within 30 days of discharge

from the same condition. Readmission is among the costliest cases in the hospital setting to

manage. Hospitals incur huge costs in managing readmission. The federal government is also

affected. The US spends $17.4 billion on readmission costs. Hospitals readmit 20% of patients

enrolled in Medicare within 30 days upon discharge and 34% of the clients within 90 days of

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completed- done is for turkey 🙂
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discharge. Unwanted and unnecessary health care costs amount to $765 billion yearly with

preventable admission accounting for $17 billion for Medicare (Warchol et al., 2020). Causes of

readmission are varied. Poor resolution of the original problem of the patient is a major cause of

readmission. The healthcare provided by professionals just relieves the pain and not the actual

problem. In such a case it is likely to reoccur. Discharge of patients too early may be a cause of

readmission. The patient is discharged before being stable enough to recover from home. In other

cases, inadequate care after discharge may make the condition worse. The nurse has a critical role

to play in the provision of care at such transition (Rezapour-Nasrabad, 2018).

Significance of the study

The significance of this study is to inform nurses of the gaps within the hospital-home

transition care and informing the necessary course of action to prevent readmission of clients. The

study will identify the major problems nursing practitioners face in transition care. Transition care

costs health facilities billions of dollars which could be avoided with proper intervention. Proper

communication and collaboration between health care providers post and Pre discharge can

provide coordinated care for better health outcomes. Adequate care post disgrace will reduce the

rate of readmission. The study will be significant to clinics and other healthcare centers. The

billions of dollars that government spends on readmission could be channeled to other treatment

avenues. Nurses and doctors can work in harmony and coordinate care during the transition.

Through education of patients, families, effective care is possible and can help to reduce


Purpose of the study

Nora Hernandez-Pupo
good background- but what exactly is the problem with what topic and how does it relate to transitional nursing
Nora Hernandez-Pupo
are you tying it to ‘readmission’ in general after any discharge?


The purpose of this study is to investigate methods nurses use to reduce the readmission of

patients after discharge. Most patients undergo a state of depression together with their kin because

of the reoccurrence of diseases that could be avoided before discharge. Going back to the hospital

makes it costly for instance to people who are not enrolled in health insurance cover (Upadhyay et

al., 2019). In the US, the costs families incur during readmission dent their economic stability,

resulting in them using coping strategies to mitigate the financial challenges. The study will assess

the major methods that can be used by clinicians to prevent readmission. Treatment of the main

condition rather than the symptoms as well as proper communication between health professionals

during discharge is essential in promoting patient recovery. In addition, nurses can take an active

role in improving care for patients in a transition phase. Making the necessary interventions can

reduce the rates of readmission in the hospital setting. The hospital should be a temporary place for

the treatment of patients before discharge within the shortest time possible. Long hospital stay is

associated with poor health outcomes and increased costs.

Research Questions

The study wishes to find key issues surrounding nursing care during the transition. The

nurse has a critical role in the management of students to minimize readmission rates. Some of

these research questions to be addressed include;

1. What strategies can hospitals put in place to prevent readmission of patients?

2. What is the role of nurses in the transition care of patients?

3. What is the role of hospital management in ensuring they reduce readmission costs?

4. What is the purpose of communication between professionals before the discharge of patients?

Nora Hernandez-Pupo
good questions


Masters essentials aligned to the study

Nursing care is an essential component in patient management. Nursing skills acquired in

training can be well utilized to provide comprehensive and timely care to all patients. During

transition care, nurses’ efforts ought to be recognized and acquired to assist patients to recover well

at home or any other transitory place or setting. Research gaps still exist that nurses can explore

and recommend necessary actions for continuous implementation in patient management. With the

proper application of nursing theories, nurses can develop philosophies that can go a long way in

changing patient care in hospitals and beyond. Developing a research problem statement should be

the pursuit of any nurse who wishes to contribute immensely in the field of medicine.

In conclusion, nurses and healthcare are synonymous. To achieve adequate patient

management, the efforts and contributions of nurses should be the core element in the development

of treatment measures for clients. Transition care, for instance, requires the input of all healthcare

professionals and adequate planning as well as communication and elaboration of the plans to

achieve the goals. Research can contribute immensely to the development of adequate care plans

for patients and their families in transition care (De Regge et al., 2017). Nursing care not only

seeks to achieve physical wellbeing but also the emotional well-being of the client and the family

in times of distress.

Nora Hernandez-Pupo
did not tie it to any essentials…



De Regge, M., De Pourcq, K., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017). The

role of hospitals in bridging the care continuum: a systematic review of coordination of

care and follow-up for adults with chronic conditions. BMC Health Services Research,

17(1), 1-24.

Rezapour-Nasrabad, R. (2018). Transitional care model: managing the experience of hospital at

home. Electronic Journal of General Medicine, 15(5).

Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on

hospital financial performance: a study of Washington hospitals. INQUIRY: The Journal of

Health Care Organization, Provision, and Financing, 56, 0046958019860386.

Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to reduce

hospital readmission rates in a non-Medicaid-expansion state. Perspectives in health

information management, 16(Summer).

Nora Hernandez-Pupo
per rubric- 5 current sources- you provided 4
Nora Hernandez-Pupo
I would be a little more specific about my problem statement and identification of the problem- good background and explanations


Phase 2- Design


Phase 2- Design

Brief literature review

For too many patients, the healthcare door is one that they consider to be a revolving one.

Approximately 20% regarding the Medicare patients usually leave the healthcare centers only for

them to be readmitted within a months time. The failure to come up with the standard discharge

processes, efficient preparation of patients and the family caregivers for discharge, effective

education of patients in regard to medications and communicate appropriately with the identified

post discharge providers is all associated with causing readmissions (Chen et al., 2021).

Through effective coordination as well as communication, planning and education, nurses

as well as the nurse case administrators can play a key role in the reduction of readmissions.

Beginning at the admission phase, there is the possibility of the mitigation of readmission risks at

the various points in the cases of pre discharge as well as post discharge periods via effective

determination of the readiness for discharge by the patients as well as the compilation of an

extensive as well as accurate form of discharge summary, coordination of care with numerous

settings as well as providers and much more.

Nursing Interventions during the Process of Discharge

Most of the studies usually connect readmissions with the lack of effective and fast follow

up by the identified primary care type of providers as well as other kinds of healthcare experts.

Patients ought to possess an effective follow up appointment that is scheduled within 48 hours to

am average of7 days after they have been discharged. There are numerous strategies in this case

which can be used which are the development of scheduling kinds of agreements with the local

clinics like the system affiliated ambulatory care kinds of clinics. There is also the creation of

Nora Hernandez-Pupo
grammar- sentence structure- meaning??
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grammar spelling sentence cohesion
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do you mean specialists?
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grammar- tooo many ideas in one sentence
PLEASE visit the writing lab prior to submitting phase 3
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do you mean case managers?
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grammar :: of Medicare


processes for the assignment of patients to an identified PCP if they lack one. It is also vital to

facilitate effective education of patients as well as the home caregivers on the significance

associated with timely as well as effective follow up (Lee et al., 2021).

Post discharge nursing related interventions

The identified period immediately after any kind of patient discharge is one that is

considered to be a vulnerable time for the patients one whereby rapid alterations can take place.

Having a follow up with the identified patients as well as the home types of caregivers soon after

the identified discharge can minimize confusion as well as effectively reinforce the follow up kind

of plans. The most common topics to be discussed in the first post discharge phone call entails the

medications as well as pending services and more (Wong et al., 2021).

Discharge to a setting other than home

When a given patient is considered to be discharged to a setting that is other than the home,

nurses as well as the NCMs can effectively play a key role in the prevention of the transfer back to

the identified hospital. Interventions to minimize the acute transfers is considered to be a quality

improvement kind of program which is associated with the provision of an evidence based kind of

guide and the necessary tools formulated to minimize transfers from the identified long term care

as well as assisted living settings to the acute care kinds of hospitals. This is essential in enhancing

patient safety as well as satisfaction and in the reduction of readmissions via early identification as

well as evaluation of the key changes in the condition of the patients (Maki et al., 2021).

Halting the readmission cycle

Nora Hernandez-Pupo
satisfaction of who
Nora Hernandez-Pupo
why do you use KIND so much- it does not fit in the sentences you are suing it in
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spell out first time used
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spell out first time used
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comma ,
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Hospital readmissions are considered to be expensive to the patients as well as the

healthcare facilities. Nurses as well as the NCMs are considered to be natural communicators as

well as educators which puts them in a perfect position to assist in the prevention of readmissions

at various points. Being familiar with as well as utilizing easily accessible, evidence based tools

can assist nurses as well as the NCMs in the management of patient transitions optimally and even

consistently (McHugh et al., 2021).

Methodology and design of the study

Intervention Mapping is considered as being a systematic as well as an iterative six phases

process which assists in the development of an intervention kind of system on the basis of the

theoretical as well as empirical and even practical information. IM was initially utilized

appropriately in the identified health promotion kind of domain to come up with programs for the

issue of smoking cessation as well as stroke prevention, HIV prevention and leg ulcer

management. There is the use of PRECEDE PROCEED MODEL to effectively analyze as well as

illustrate the identified scale along with causes and even impacts regarding Health issues and in the

identification of the target population.

Procedure & participants

A literature kind of search on the identified frequency as well as impacts regarding

ineffective hospital discharge issue will be performed. There will be the performance of a large

kind of qualitative study on the identified patient handovers between the identified acute care

healthcare centers as well as the primary care in the US. This will be vital in the identification of

the behavioral as well as the environmental Level determinants impacting ineffective healthcare

centers discharge. The study to be performed will adhere to RATS which stands for relevance as

Nora Hernandez-Pupo
you did not explain this- please revisit and revise for final submission
Nora Hernandez-Pupo
Intervention Mapping is not a new theory or model; it is an additional tool for the planning and development of health promotion interventions. It maps the path from recognition of a need or problem to the identification of a solution.- What is your methodology?
Nora Hernandez-Pupo
do not know why you put this here- this needs to be reworded within the sentence if you want to use it


well as Appropriateness, Transparency and Soundness guidelines for the qualitative types of

studies. Data analysis as well as analysis will comprise of multi-method kind of qualitative study

inclusive of the individual as well as the focus group kinds of interviews, process maps and the

artefacts Analysis.

Intervention Results, performance Goals & change Goals

There was also the identification of the desired results regarding the intervention as well as

formulated particular performance objectives for the identified target population like writing of a

complete as well as accurate and even timely kind of discharge letter by the identified hospital

physician. This led to a step by step kind of checklist regarding what needs to be achieved so as to

attain the most effective results. It is vital to facilitate the identification of the necessary steps

needed to be tweaked so as to impact the performance goals and eventually the intervention results.

There was the identification of the most vital kind of determinant such as the lack of knowledge as

well as comprehensive understanding between the healthcare center as well as the primary care

types of providers which are required to be altered as well as combined these with the performance

goals to design the alteration goals.

Sampling methodology

Stratified sampling

In this method, the identified population is usually first divided into key subgroups or even

strata who are all involved in sharing of the same features. It is usually utilized when the

researchers may reasonably anticipate the identified measurements regarding the interest to vary

between the distinct kinds of subgroups and there is the need to make sure there is representation

from all the identified subgroups. In this kind of sampling Methodology, the identified study

Nora Hernandez-Pupo


sample is usually obtained via taking equal and fair sample sizes from each of the given stratum. In

the stratified kind of sampling, it is also considered to be vital to select non-equal sample sizes

from each of the identified stratum.

This is vital in ensuring there is the achievement of a highly realistic as well as accurate

estimation regarding the health outcomes regarding nurses across the region while for simple

random kind of sampling, there would be the over representation of the nurses from the identified

healthcare centers. It is vital to understand that the fact that the given sample was effectively

stratified ought to be put into consideration at the identified analysis stage. This kind of sampling

Methodology helps in the improvement of accuracy as well as representativeness regarding the

outcomes by the reduction of the sampling bias (Valliant et al., 2018).

Necessary tools

The necessary tools are audio recorders as well as form plus online kind of questionnaire.

The audio recorder is utilized for the key aim of recording sound on the discs as well as tapes and

films. The audio kind of information is considered to be highly suitable since it can effectively

meet the key needs regarding a wide range of individuals along with offering alternatives to the

printing of data gathering tools (Narasimharao et al., 2017). Form plus is associated with letting an

individual to effectively create strong forms to assist in the collection of the information which is

needed. It is vital in the creation of online forms for getting actionable trends as well as measurable

kinds of responses.

Any algorithms or flow maps created

Nora Hernandez-Pupo
Nora Hernandez-Pupo
kind again….
Nora Hernandez-Pupo
is this for your study? what you are using or are you reporting something you read and found useful- unable to follow- no focus or cohesion
Nora Hernandez-Pupo
Sample size, inclusion, exclusion criteria, flow charts or graphs, a place where the study was to take place, ethical considerations etc.. should be developed.




Chen, J., Wijesundara, J. G., Patterson, A., Cutrona, S. L., Aiello, S., McManus, D. D., … &

Houston, T. K. (2021). Facilitators and barriers to post-discharge pain assessment and

triage: a qualitative study of nurses’ and patients’ perspectives. BMC Health Services

Research, 21(1), 1-15.

Maki, S., Nagai, K., Ando, S., & Tamakoshi, K. (2021). Structure and predictors of in-hospital

nursing care leading to reduction in early readmission among patients with schizophrenia in

Japan: A cross-sectional study. PLoS one, 16(4), e0250771.

McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021).

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality,

readmissions, and length of stay: a prospective study in a panel of hospitals. The

Lancet, 397(10288), 1905-1913.

Oh, E. G., Lee, H. J., Yang, Y. L., & Kim, Y. M. (2021). Effectiveness of discharge education with

the teach-back method on 30-day readmission: a systematic review. Journal of patient

safety, 17(4), 305-310.

Valliant, R., Dever, J. A., & Kreuter, F. (2018). Practical tools for designing and weighting survey


Wong, C. H., Cheung, W. K., Zhong, C. C., Yeoh, E. K., Hung, C. T., Yip, B. H., … & Chung, V.

C. (2021). Effectiveness of nurse-led peri-discharge interventions for reducing 30-day

hospital readmissions: Network meta-analysis. International Journal of Nursing Studies,



The final submission combines the other four phases into one paper.You will combine Phase I, Phase II, Phase III, and Phase IV to make Phase V.You edit and format your paper so your paper will flow for the reader. This paper will need to be corrected with all the feedback provided from previous papers. Include conclusion and learning experiences from the essentials and from the class.

Do not forget to document limitations and implications for future research/practice.

Cites all data obtained from other sources.

APA citation style is used in both text and bibliography

Cites most data obtained from other sources.

APA citation style is used in both text and bibliography.

Cites some data obtained from other sources.

Citation style is inconsistent or incorrect.

Does not cite sources.

Please refer to the sample APA paper provided to ensure you are compliant.

Pay attention to APA formatting, spelling, and grammar. Your similarity index/plagiarism score must be below 10%. Higher scores may impact your grade.