Current healthcare literature provides us with strong evidence that both patient safety and quality are at risk for patients undergoing transitions across care settings. Transitional care has been defined as "a set of actions designed to ensure the coordination and continuity of care as patients transfer between different locations or different levels of care within the same location" (Coleman, Mahoney, & Parry, p.246). Transitions, or handoffs, are particularly perilous for vulnerable patients with complex needs and may contribute to higher rates of health services use, spending, and hospital readmissions. With the passage of the Accountable Care Act of 2010, a variety of transitional programs and protocols have come to the fore to help patients with complex needs avoid hospitalization and to interrupt patterns of frequent use of health care services. Despite the seemingly obvious potentially negative effects of transitions, benefits exist as well. For example, a new primary care provider or a new team of nurses may notice signs and symptoms overlooked in the past.
Although we, as nurses, look at transitions as a necessary, and inevitable, component of patient care, our patients and their families often express feelings of anxiety, a lack of understanding about self-care and disease management, disregard for their preferences in planning care, and a sense of abandonment. We routinely "handoff" care from shift to shift and from setting to setting. Transitions for neuroscience patients include moving from critical care to a less "intense" setting, from in-patient acute care to rehabilitation or long-term care settings, and to home. Despite their complexity, neuroscience patients often spend very limited periods of time with us receiving care.
Perhaps more significantly for our patients are the transitions they face in their lives related to the neurologic changes disease has wrought. For many of them, things have changed quickly and dramatically, bringing an end to life as they have known it. These life transitions are challenging because they force the individuals affected to let go of the familiar and face the future with a feeling of vulnerability. Life transitions linked with neurologic illnesses include a string of losses that may include loss of role, loss of "person," and the loss of a sense of where one fits in the world. A stroke, a ruptured cerebral aneurysm, seizures, or the diagnosis of multiple sclerosis, Parkinson disease, or another progressive degenerative disorder forces life transitions on patients and their families. They must learn new ways to adapt to permanent change or relearn skills they cannot even remember ever learning. They are anxious, frightened, and changed.
Frequently, these times of transition become a person's major life-defining moments-moments after which a life is forever changed. Tough transitions remain a part of the individual forever. Life transitions are often difficult, but they have a positive side, too. They provide us with an opportunity to assess the direction our lives are taking. They are a chance to grow and learn.
How can we ease these transitions? Communicate. As we handoff or transition care to one another, provide not only basic information about physical findings, monitoring parameters, or progress in therapy, but timely insights and perceptions related to the patient's frame of mind and his or her coping skills. Involve the patient and family at each step of the transitional journey. Assure seamless continuity of care-patients and their families need to know who is responsible for care at each juncture. Be intentionally present. Listen.
Successful transitions are not easy, but they represent paths to follow in life.
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