Theory-guided Practice: Application of Transitions Theory

Our first featured article from the latest ANS issue (coming soon!) is titled “Reducing 30-Day Readmissions Through Nursing Science: An Application of Transitions Theory With Best Practice Guidelines” by Bridget Stixrood, MSN, RN, CNL.  In this article, Ms. Stixrood provides an exemplar of theory-guided practice!  While the article is featured, you can download it at no cost.  We welcome your feedback and comments!  Here is a message from the author about her work and her perspective:

Bridget Stixrood

I am honored to present my article outlining the Transition Management Model to this issue of ANS.

 The Transition Management Model was completed as a part of my MSN program. The goal of the project was to improve care transitions for patients and reduce 30-day readmission rates for an Independent Health Network. At this unique healthcare setting nurse care coordination was utilized to manage care for complex Medicare and Medicaid covered individuals. Upon initial design of the project I quickly became inspired and energized by the application of nursing science to frame best practice guidelines. I found that nursing theory provides enough flexibility to adapt to the unpredictable nature of healthcare politics, policies and emerging best practice guidelines.

This project underscores the overwhelming importance of nursing practice to improved health outcomes and reduced 30-day readmission rates. I believe some project success could be attributed to the holistic nature of nursing practice. As nurses we look at an individual’s whole health story including spiritual, mental, physical and environmental.

Behavioral health was particularly difficult to address in the Transition Management Model. Those with mental illness have an added barrier to care when they are symptomatic and need a higher level of management. Applying the Transition Care Model to mental health transitions could be a next step for this project. Improving community partnerships and using nursing science to address the complexities of healthcare in the US is desperately needed. I am curious about what types of breaks in healthcare delivery are you seeing in your community? How can we build a practice that maintains integrity despite what political constructs we work within?

This article is meant to be read as a catalyst and an example of how nursing theory, in this case Transitions Theory by Meleis, can be a useful tool in navigating the complex health stories of our patients and the healthcare environment we function within.

I obtained my MSN from Pacific Lutheran University in 2018. I obtained my Clinical Nurse Leader certification soon after graduation. After working as a labor and delivery nurse for a year while also working at the Pierce County Jail, I fell in love with nursing in the jail setting. I am currently working as a nurse at the King County Correctional Facility. I am passionate about nursing science, mental health care and public health.

I look forward to reading your comments and strengthening our practice together.