Annotated Bibliography on Transitions of Care.

Posted: November 13th, 2022

Annotated Bibliography on Transitions of Care.


An annotated bibliography is a combination of the words annotation and bibliography. An annotation is a set of notes, comments, or critiques. A bibliography is a list of references that helps a reader identify sources of information. An annotated bibliography, then, is a list of references that not only identifies the sources of information but also includes information such as a summary, a critique or analysis, and an application of those sources’ information.Annotated Bibliography on Transitions of Care.


Your Module 2 Assignment (due in Week 5) will be a paper on nurse leadership during transitions of care for two selected entities. In preparation for that paper, you will develop an Annotated Bibliography and submit it to your Instructor for feedback.Annotated Bibliography on Transitions of Care.

To prepare:

Select a transition of care (hospital, specialty care, rehabilitation, nursing home, homebound, etc.).
Use the Walden Library and other reputable academic resources to locate 5 scholarly resources on nurse leadership during this transition of care. Identify what constitutes effectiveness (i.e., cost, care management, best/effective providers, best setting, sustaining outcomes) for this transition of care within each setting. What evidence supports this transition of care or transition of care intervention?
Review the Writing Center resources on annotated bibliographies and scholarly writing. Also review the Week 4 Assignment Rubric for specific details about the requirements for your annotated bibliography.


Create an annotated bibliography of the 5 scholarly resources you located on your selected transition of care. Follow the annotated bibliography format presented in the Writing Center resource.Annotated Bibliography on Transitions of Care.

*Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at All papers submitted must use this formatting.

The Importance of Nursing Leadership During Homebound Transition of Care From the Hospital: An Annotated Bibliography

Care transition from one care setting to another is an important milestone in all patient’s care continuum. Care transition means coordinating continuity of care from one care setting to another (Zangerle et al., 2016). Many authors and scholars agree that it is the weakest point in the process of caring for the patient. Therefore, if not managed properly, itbmay result in negative outcomes and adverse effects to the patient. These negative outcomes include unnecessary readmissions and even mortality in the worst case scenario (Fuji et al., 2012; Abrashkin et al., 2012; Werner et al., 2016).Annotated Bibliography on Transitions of Care. Werner et al. (2016) argue that care transitions are usually costly and effective care management is therefore crucial in reducing costs and preventing adverse outcomes like noncompliance to treatment due to misunderstanding at discharge. This paper looks at the evidence available about transition of care. It further narrows down ti transition of care fron the hospital setting to the home setting.Annotated Bibliography on Transitions of Care.

Annotated Bibliography

Abrashkin, K.A., Cho, H.J., Torgalkar, S., & Markoff, B. (2012). Improving transitions of care from hospital to home: What works? Mount Sinai Journal of Medicine, 79(5), 535–544. DOI: 10.1002/msj.21332

The authors in this paper try to paint the ideal scenario of effective care transition according to them. They argue, rightly, that it is the quality of the care transition that ultimately affects factors such as the patient’s compliance to treatment and their general outcome.

These authors also argue, rightly, that timely discharge summaries that are shared with the next level provider, post-discharge two-way communication, and follow up are important steps in ensuring an effective patient care transition from the hospital to the home setting. However, the authors clearly miss the point when they insist that the most important players in this care transition are physicians and pharmacists. Nurses are only mentioned in passing, as merely part of the care team. This is misleading. Nurses are the leaders and the most important link in care transitions. In fact, they are the primary contact between the provider and the patient.Annotated Bibliography on Transitions of Care.

Fuji, T., Abbott, A.A., & Norris, J.F. (2012). Exploring care transitions from patient, caregiver, and health-care provider perspectives. Clinical Nursing Research, 22(3), 258-274. DOI: 10.1177/1054773812465084

Fuji et al. (2012) aver that if care transitions are not well managed, negative patient outcomes like readmissions inevitably occur. They examined the nature of care transitions from the standpoint of the patient, the caregiver, and the provider. The qualitative descriptive study methodology that they used was apt. What they assessed were the perceptions of these groups of stakeholders on their role, the nature of care transition, barriers to seamless transition, and possible ways of surmounting the barriers. Among the answers they got were that it is important to plan for admissions (and discharges), and that a multidisciplinary approach is necessary to prepare patients for discharge. All these are important factors that nurse leaders must consider as yhe drivers of patient welfare during transitions to the home environment.Annotated Bibliography on Transitions of Care.

Weaver, F.M., Perloff, L., & Waters, T. (1999). Patients’ and caregivers’ transition from hospital to home: Needs and recommendations. Home Health Care Services Quarterly, 17(3), 27-48. DOI: 10.1300/J027v17n03_03

The authors opine that the need for effective care transition from the hospital to the home environment has become even more important. This is because hospital stay is reducing in duration, with preference being goven to continuation of care at home. Theirs was a descriptive study of hospital patients discharged to continue care at home. Data collected revealed that there was a positive correlation between satisfaction with care at home and the amount of information received from the discharging team. In this, it is instructive to note that nurse leaders have the most important role in ensuring this information on discharge is timely, accurate, and appropriate for the patient and the next of kin.Annotated Bibliography on Transitions of Care.

Werner, N.E., Gurses, A.P., Leff, B. & Arbaje, A.I. (2016). Improving care transitions across healthcare settings through a human factors approach. Journal for Healthcare Quality, 38(6), 328–343. Doi: 10.1097/JHQ.000000000

These authors argue that the quality of care transitions is coming into sharp focus lately. This is because preventable readmissions and other adverse outcomes are becoming more frequent, with patient and next of kin satisfaction dipping due to low quality of the transitions. They thus suggest that significant financial investment by the provider is necessary to train staff for better care transition services. These staff include the nurse leaders who are the primary contacts. They also suggest the adoption of the Human Factors and Ergonomics (HFE) systems approach that will assess the human factors that impede the success of an effective care transition model in the healthcare system.Annotated Bibliography on Transitions of Care.

Zangerle, C. & Kingston, M.B. (2016). Managing care coordination and transitions: The nurse leader’s role. Nurse Leader, 14(3), 171-173. DOI:10.1016/j.mnl.2016.04.002

On their part, Zangerle et al. (2016) suggest the employment in care transitions of six principes. These were formulated by nurse leaders from the American Organization of Nurse Executives (AONE) and the American Academy of Ambulatory Care Nursing (AAACN).Annotated Bibliography on Transitions of Care.


The fact that effective and thoughtful care transitions are crucial in discharged patients’ outcomes is not in dispute. However, there is need for nurse leaders and team members in the care transition team to step up their efforts in their role as patient educators and advocates.Annotated Bibliography on Transitions of Care.


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