Discussion Board Nursing Research

Prepare a 350 word draft of a clinical problem that you would like to
use for your Research project.There should be an introduction to the
problem (as to why it is a problem) that is documented with
literature, a clear problem statement (one declarative sentence that
begins with “The problem is…”, and a purpose to your project. Post
this as your Initial response. (Essential I-IX).

Discussion Rubric

Make sure you provide appropriate references (2-3) and utilize APA
style. Each discussion will be allocated to a specific Master’s

note: added phase 2 of my research project.



Planning Stage 2- (Design Phase) of a Research Project

Student name

Florida National University

Planning Stage 2- (Design Phase) of a Research Project
Heart failure is one of the most common types of chronic conditions
among the elderly, which results into increased readmissions globally.
This statistic is attributable to poor coordination and communication in
the transition care settings. The various care settings include skilled
nursing facilities, acute-care hospitals, long-standing care facilities
and ambulatory stay (Naylor et al., 2017). This research paper is aimed
at investigating the reason for poor continuity of care in transition
care facilities. A detailed literature review was performed regarding
the standard of care in such settings for patients with heart failure.
The research methodologies used include case study methods, interviews,
and administration of questionnaires. Probability and non-probability
methods including stratified sampling and convenience sampling were used
as the sampling methodologies. The necessary tools for data collection
include questionnaires, interviews, schedules and observation
techniques. In addition, an algorithm was created during this design
phase. Thus, an insight into the design phase is sought and discussed

Literature Review

Heart failure is a prolonged condition that has been highlighted as
one of the top causes of public health complications in the world. The
American Journal of Accountable care provides detailed information on
heart failure as a public health problem. According to this journal,
there are numerous causes of readmission of patients undergoing the
transition care model (A Literature Review of Heart Failure Transitional
Care Interventions, 2019). The journal highlights various issues, such
as early discharge, poor management of underlying problems, poor
coordination among key stakeholders and early discharge of patients as
the major causes of readmission. All such issues can, however, be
prevented and thus this research will discuss some of the coping
methods. In addition, the US medical beneficiaries discuss the quality
and safety in the transition care model (Teno et al. , 2018). Some of
the beneficiaries state their experiences following being admitted into
the transition care model. This article complements the previous article
by adding real life case study analysis of patients who have been
previously admitted to the transition care. Further, interviews of
clinicians working in the transition care model are highlighted with an
explanation of failure to conduct follow up visits of particular
The American Journal of Public Health explores the affordability of
the transition care and the quality of care that some patients can be
able to afford. The article has explored the different forms of care
based on affordability from the cheapest to the most expensive
(Hirschman et al., 2015). This research has shown that since most
patients are not able to afford the premium packages, they acquiring
poor quality of care. A randomized clinical trial has also been
conducted testing patient home based care (Adepoju et al. , 2015). This
study involved collecting data and observing willing patients who were
undergoing the transition care model and writing down their experiences.
Given such an extensive research, the study has filled in the gaps of
the previous articles in that the patients were keenly observed and all
their experiences duly registered. Thus, these articles form a basis for
this research project for they provide the researchers with a founding
ground of conducting their research.

Methodology and Design of the Study

The research methods used in this study include case studies,
interviews, as well as questionnaires. The case study entails an
analysis of patients who were undergoing the transition care model. The
selected patients must be willing to participate in the study and
provide accurate feedback on their progress. The case study will be
undertaken within the period of the admission of the patient into the
hospital to determine their experiences when they are subjected to the
transition care model and whether they are readmitted to hospital or
released to ambulatory stay. During the case study, detailed interviews
and observations of the patients willing to take part in the research
can be conducted. A longitudinal study can be conducted where the
patients undergoing the transition care model are observed throughout
the process. Such an approach is beneficial for research purposes and
can be used as a research methodology for the research project.
Interviews are also an important form of research methodology that
can be used. The researcher will conduct interviews with everyone who is
affected by the transition care system including the patients, their
care takers, family, as well as the clinicians and the nurses. The
reasons for poor continuity of care include lack of follow ups from the
physicians and therefore it is important to interview them and establish
the reason for such behaviour. Additionally, most family members and
care givers lack the necessary information regarding the best forms of
care for their patients, which makes them an important part of data
collection (Adepoju et al. , 2015). The patients can be interviewed and
allowed to express their thoughts regarding the possible improvements.
Additionally, questionnaires can be administered to the same group of
individuals. These questionnaires allow individuals to express their
genuine opinions privately by answering multiple choice questions,
closed questions, and open ended questions. Thus, questionnaires and
interviews are a critical aspect of the methodology of the research.

Sampling Methodology

The sampling methodology for this research will entail both the
probability sampling and the non-probability sampling methods. In the
probability sampling method, stratified sampling can be employed. This
approach will involve dividing the group of people for the study into
subgroups that share common interests. All physicians and nurses for
instance could be placed into one group whereas the patients and their
care givers could belong to another group. The study can also be done in
three different settings where results will be compared for patients
from one hospital to those from another hospital. This form of sampling
is important for it ensures accurate estimation of health outcomes in
the transition care setting. Such a projected result can be attributed
to the increased representation, which in turn reduces sampling biases.
Non-probability sampling will also be a key feature of sampling method
for this research. In this case, convenience sampling will be used,
which entails selecting participants based on their willingness to
cooperate and their availability for the study. Thus, stratified and
convenience sampling are the two important sampling methods that can be
used for this research.

Necessary Tools

The necessary tools for the research include questionnaires,
interviews, schedules, and observations for data collection. The
questionnaires deal with significant and important topics which are
carefully stated, complete, short and clear. Interviews are the most
important tools for they provide flexibility during the research phase.
They can be adjusted to suit the population being interview and
therefore improve the chances of collecting accurate data. The
interviews allow for deep and direct research, examination of the known
information and exploring past and future information. Schedules can be
used as necessary tools for data collection where researcher
questionnaires can be used for interview purposes. This approach
increases the percentage of responses, makes it possible to observe
other factors and any defects can be detected and corrected immediately.
On the other hand, observations will serve an expressed research
purpose. They are methodically planned, and require employment of
personal skills and can be administered formally and informally. Thus,
these tools are important for they will ensure necessary data

Algorithms and Flow Maps Created

Various algorithms for the research were created in order to help the
researcher to follow a systematic form during the study. The flow maps
summarise the steps of investigation and highlight the important aspects
of the study.

eart failure patients
medical records

nfirm eligibility through communication
with ph
ysicians and also
obtain written

study participants who are heart failure
nformed consent form
be signed
Obtain demographic data baseline (quality of life, symptom intensity
al status)

to enhance data representation of entire population

care systems
care plus transferred into the transition care model

quarterly within a period of a year
post enrolment
Readmission rate
Quality of life
Symptom intensity
Functional status
Satisfaction of care


In conclusion, the design phase is focused on conducting a detailed
research regarding the care for patients with heart failure in the
transition care settings. A thorough literature research has been
conducted regarding transition care model and the continuity of care
being offered in these setups. Most of the causes of readmission in
hospitals can be avoided if some changes are implemented in the care
plan of these patients. The methodology and design of this research will
be comprised of case study methods, interviews, and administration of
questionnaires. The sampling methodology will involve the procedure of
subdividing the interested parties into subgroups for accuracy and
efficiency. The necessary tools for data collection and analysis have
also been highlighted including interviews, schedule completions,
questionnaires and observations. Various flow charts for the study have
been developed to ensure the study is conducted in a systematic manner
and that all aspects of the study have been considered. Thus, the design
phase of this research project has been discussed and analysed in this

A Literature Review of Heart Failure Transitional Care Interventions. (2019). AJMC. Retrieved from https://www.ajmc.com/journals/ajac/2017/2017-vol5-n3/a-literature-review-of-heart-failure-transitional-care-interventions.
Adepoju, O. E., Preston, M. A., & Gonzales, G. (2015). Health care disparities in the post–Affordable Care Act era. American Journal of Public Health, 105(S5), S665-S667.

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., &
Naylor, M. D. (2015). Continuity of care: The transitional care model. Online J Issues Nurs, 20(3), 17-32.
Naylor, M. D., Hirschman, K. B., Hanlon, A., Barg, R., McCauley, K.,
Shaid, E., & Pauly, M. (2017). Testing the patient-centered medical
home plus transitional care model. Innovation in aging, 764-764.
Teno, J. M., Gozalo, P., Trivedi, A. N., Bunker, J., Lima, J.,
Ogarek, J., & Mor, V. (2018). Site of death, place of care, and
health care transitions among US Medicare beneficiaries, 2000-2015. Jama, 320(3), 264-271.

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