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Background Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions. Methods A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements. Results The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses’ roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population. Linking Evidence to Action Key insights on optimizing the nurses’ roles and scope of practice during care transitions included having nurses provide “warm hand-offs” and serve as the “go-to person.” The panel also identified current challenges to optimizing the nurses’ roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions.A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements.The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses' roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population.Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

This article reports results from a systematic review used to inform the development of a best practice guideline to assist nurses in understanding their roles and responsibilities in promoting safe and effective client care transitions. A care transition is a set of actions designed to ensure safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health care providers, or location.

Aim : The aim of this paper is to highlight evidence and key nursing practice, education, organization and policy recommendations from the original and revised Registered Nurses’ Association of Ontario Best Practice Guideline, Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). This paper introduces the notion of dyspnea as the sixth vital sign and presents evidence from the RNAO Best Practice Guideline and other relevant literature to support and enhance nursing care of dyspnea in clients with COPD. Background : COPD is an increasingly serious health issue. Nurses have significant opportunity to positively influence client outcomes and quality of life by assessing dyspnea, identifying problems, and applying appropriate evidence-based interventions. Best practice guidelines developed by the RNAO provide a framework to enhance nursing practice and client care. Design : A panel of nurses was assembled for the initial development of the guideline and more recently, the revision to the original guideline. Method : A structured evidence review based on the scope of the original guideline and supported by three clinical questions was conducted to capture the relevant literature and guidelines published since the original publication. Results : As a result of this work recommendations for nursing practice and education are discussed. Organizational and policy recommendations are also outlined. Conclusions : Nurses have opportunity to positively influence client outcomes and quality of life by assessing dyspnea, identifying problems, and applying appropriate evidence-based interventions. Relevance to Clinical Practice: Recommendations made in the best practice guideline will enhance nursing care of dyspnea in clients with COPD and dyspnea should be recognized as the sixth vital sign in individuals with COPD.