Transitional Care Nurses (TCN) - Key Elements of Success

The Transitional Care Nurse role can provide an important option in the career ladder for nurses. The holistic and autonomous nature of the TCN is an attractive position to nurses seeking a challenging and very vital role in assisting vulnerable patients to manage complex chronic illnesses.

Requirements/characteristics needed to successfully fill this role include:

• Strong clinical skills, including an understanding of and ability to implement evidence-based care;

• Understanding of the health care system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals;

• Understanding of the community-based social service delivery system and its interaction with the health care system;

• Ability to manage patient complexity and multiple patients with diverse needs;

• Comfort with an independent role;

• Experience in providing care in a hospital and home setting;

• Flexibility and adaptability;

• Assertiveness, maturity, and confidence;

• Ability to think broadly and longitudinally, constantly assessing and anticipating the needs of the patient and his/her environment;

• Effective communication skills including both good listening and verbal and non-verbal abilities; and

• Natural ability to collaborate and facilitate relationships and consensus among the patient, family, and multidisciplinary providers from many different disciplines.