Nurses’ Role in the Coordination and Continuum of Care

Subject: Nursing
Pages: 4
Words: 1242
Reading time:
5 min
Study level: School

Care coordination refers to the type of service that is provided to patients outside of the healthcare facility. The between-visit care has a positive impact on health and reduces the risk of disease progression. Care coordination and continuum of care are based on the notion of person-centered assessment and care. It represents a philosophical approach to the development, application, and delivery of care services that are respectful, responsive, and aligned to the preference of individual patients. In light of individual needs and circumstances being vastly diverse and unique, care providers and organizations also need to become more adaptive, creative, and innovative in providing meaningful and valuable supportive services (McCormack & McCance, 2016). The development of this essay focuses on addressing nurses’ role in the provision of care coordination and potential approaches to the continuum of care, identifying suitable support and inherent challenges and ethical considerations that may exist.

There are four essential elements that ensure effective coordinated care. The first is to allow for access to all needed health care services and needed providers. Nurses and doctors have to identify and communicate the treatment plan to their patients. The second element is to develop collaborative communication with the clients. Here, it is important to ensure smooth transitions through providers and care plans, so the patient’s experience is positive. Nurses have to double-check the treatment plans so they address all of the patient’s needs, and all specialists involved in the process are able to contact patients regularly.

Thirdly, care coordination has to focus on the whole needs of the patient and their family. This element may be challenging because of the diverse cultural or religious backgrounds of patients. Hence, cultural competence, which is an inclusive concept used to explain strategies developed to ensure that nursing students can offer standard healthcare to people of diverse backgrounds, is required of nurses. Treating patients with respect and dignity, as well as engaging their families in the process of recovery, has a positive effect on the treatment plan realization and improves patient outcomes. The fourth element is to provide information to the patient and family in a manner they can understand. This way, the patient’s experience is enhanced as effective communication and a person-centered approach ensure patient satisfaction and more effective treatment due to lack of misunderstanding.

Therefore, an effective strategy for collaborating with patients and their families to achieve desired health outcomes would be scheduling a meeting. At that meeting, a nurse and, if possible, specialists that are involved in the care plan would communicate the measures that are needed to be taken and address the expected patient outcomes. During the meeting, all the questions from family members should be answered to minimize misunderstanding. Further, a nurse should schedule regular calls and video-chats and keep in contact with the patient through messaging.

An example of a drug-specific educational intervention can be seen in the case of asthma treatment. For instance, a patient has been prescribed Salbutamol 100 micrograms per dose with a metered-dose inhaler (MDI), CFC-free. A patient should inhale one or two puffs up to four times a day when required to relieve asthma symptoms. In this case, the nurse should deeply explain to the patient and his family that to achieve the asthma quality care levels or standards as reflected by NICE, there is a need to carry out an asthma review every single year (Swan et al., 2019). Moreover, the educational intervention should include training on how to properly use the inhaler.

Various reviews have explored the impact of cultural competence initiatives on nurses. The outcomes of these reviews indicate that cultural competence studies can be useful in improving knowledge, patient satisfaction, skills, and attitudes (Flood & Commendador, 2016). However, some current studies outline the lack of enough evidence concerning the relationship between developed organizational behaviors and cultural competency or patient health outcomes (Swan et al., 2019). There is also limited consensus on the most appropriate means of developing cultural competency and heated debate as to whether the initiatives to develop cultural competency can cause decreased health disparities triggered by racial discrimination.

Examination of literature indicates that patient-centered health care is becoming highly prominent as a part of international health care reform. The application of the patient-centered care approach in coordination is driven by an understanding that working with those being cared for often derives more positive outcomes than the prescriptive, universal application of care strategies. There is a growing body of evidence indicating that patient-centered health care demonstrates improvement in patient experience, care quality, and, subsequently, health outcomes. In achieving patient-centered assessment and care, each person should be treated with dignity, compassion, and respect, at the same time providing care that is personalized and coordinated with the needs and preferences of those being cared for.

The primary aim of the doctor is for the patients’ health regardless of how they feel. Thus, they are concerned with ensuring continuity in the treatment program. Failure to consider this will result in abandonment, which is against the ethics of the doctors. Hence, the physician should continue to take care of the patient until they get an alternative doctor. The doctor should ensure that there is continuity of interventions by availing all the records of the patient to the new practitioner.

Ensuring a positive patient experience in the coordination of care may require the implementation of change management techniques. Change management focuses on managing human emotions and the concerns of agents and assists in transitioning individuals, teams, and the entire organization from a current state to a desired future state. Hence, nurses have to ensure that patient perceives healthcare providers as partners in order to develop an effective in-between visit treatment plan. This way, a positive patient experience will improve adherence to the care plan after the patient leaves the doctor’s office.

The possible consequences of an ethical approach to care and its effects on decision-making have a positive effect on patient satisfaction. Patient satisfaction is associated with increased adherence to the treatment plan, hence, ensuring a continuum of care. Providing educational interventions to train patients to use specific devices is essential and will have a significant positive impact on patient experience (Ortiz, 2018). This will be done by increasing the effectiveness of treatment and decreasing the adverse effects of asthma symptoms.

Therefore, making an ethical decision as well as treating patients with dignity and respect promotes improved long-term collaboration and communication between the patient and the nurse. Luchsinger et al. (2020) noted the positive correlation between the patient experience and the effectiveness of care coordination in the study. Education and communication of the treatment plan’s goals and measures help to reduce errors in between-visit care, which is most often associated with a lack of knowledge or training. Moreover, by ensuring trusting relationships and developing communication channels, nurses are more likely to provide their consultation on-demand because of a lack of patient hesitation.

Care coordination is an effective model of improving patients’ health and well-being in the long term. It saves time and resources for both patients and the healthcare facility. A patient-oriented strategy and implementation of change management techniques improve the patient experience. Nurses are required to possess good communication skills and be culturally competent in order to meet the need of patients with diverse backgrounds. Making rational and ethical decisions is another important element of the continuum of care. Hence, adhering to the ethical codes of conduct in healthcare is a priority for nurses.


Flood, J. L., & Commendador, K. A. (2016). Undergraduate nursing students and cross-cultural care: A program evaluation. Nurse Education Today, 36, 190-194. Web.

Luchsinger, J. S., Jones, J., McFarland, A. K., & Kissler, K. (2019). Examining nurse/patient relationships in care coordination: A qualitative metasynthesis. Applied Nursing Research, 49, 41-49.

Ortiz, M. R. (2018). Patient-centered care: Nursing knowledge and policy. Nursing Science Quarterly, 31(3), 291-295.

McCormack, B. & McCance, T. (Eds) (2016). Person-centred practice in nursing and health care: Theory and practice (2nd ed.), p. 13.

Swan, B. A., Haas, S., & Jessie, A. T. (2019). Care coordination: Roles of registered nurses across the care continuum. Nursing Economics, 37(6), 317-323.