From Transition Clinic to Nursing Leadership: Adapting an Evidence-Based Model from Congenital Heart Disease to Oncology

Abstract

Introduction. Standardized educational and multidisciplinary support interventions delivered through a Transition Clinic (TC) represent a key component in the management of patients with congenital heart disease (CHD) during the transition from pediatric to adult care. Although CHD-specific TC models are increasingly implemented, empirical evidence and transferable guidance for their application in other clinical settings, including oncology, remain limited. This work aimed to describe the evidence-based TC model developed at IRCCS Policlinico San Donato and conceptually assess its adaptability to oncology, identifying transferable components and context-specific modifications, with particular attention to continuity of care, empowerment, and self-management.

Methods. The CHD-specific TC model comprises three principal components: personalized education for patients and families concerning the clinical condition; educational interventions, psychological support, and peer counselling aimed at promoting empowerment and self-management; and multidisciplinary coordination led by a Transition Coordinator who facilitates communication among patients, families, and healthcare professionals. A qualitative, exploratory conceptual analysis was conducted to examine the model’s adaptability to oncology, considering organizational context, multidisciplinarity, patient empowerment, self-management, and continuity of care. Potential adaptations were evaluated on the basis of experience with the CHD model and the international literature.

Results. The analysis identified three potentially transferable components: structured patient and family education, integrated psychological and peer support, and multidisciplinary care coordination. It also highlighted the need for context-specific adaptations reflecting the organizational and clinical characteristics of oncology pathways. These findings supported the formulation of preliminary principles for developing a patient-centered oncology Transition Clinic.

Discussion. The CHD-specific TC model provides a conceptual framework for designing structured transition pathways in oncology. Its adaptation may strengthen continuity of care, patient empowerment, self-management, and nursing leadership. Subsequent implementation studies will be required to evaluate the model’s feasibility, effectiveness, and organizational sustainability in oncology settings.