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  1. Lee, Jason DNP, RN-BC, ANP-BC, CCRN


The middle-range transitions theory guided the TCI implementations.25 In this study, the transitions theory assisted the advanced practice registered nurse (APRN) to achieve a smooth and effective patient transition from hospital to home. This theory has four major components: 1. nature of transition, 2. transition condition, 3. pattern of response, and 4. nursing therapeutics.25 Based on the theoretical framework, patients can experience single or multiple changes in health and illness during readmissions and discharges. Patients who are well informed about the nature of their health will engage in their care.26 Likewise, a transition can facilitate or hinder an effective outcome.27 The patterns of response were conceptualized as process indicators and outcome indicators.28 Operationally, in the current study, the response pattern was measured as the rate of 30-day readmission. Nursing therapeutics was the TCI