how to transition in a research paper

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Effective Transition Words for Research Papers

What are transition words in academic writing?

A transition is a change from one idea to another idea in writing or speaking and can be achieved using transition terms or phrases. These transitions are usually placed at the beginning of sentences, independent clauses, and paragraphs and thus establish a specific relationship between ideas or groups of ideas. Transitions are used to enhance cohesion in your paper and make its logical development clearer to readers.

Types of Transition Words

Transitions accomplish many different objectives. We can divide all transitions into four basic categories:

• Additive transitions  signal to the reader that you are adding or referencing information
• Adversative transitions  indicate conflict or disagreement between pieces of information
• Causal transitions  point to consequences and show cause-and-effect relationships
• Sequential transitions  clarify the order and sequence of information and the overall structure of the paper

Additive Transitions

These terms signal that new information is being added (between both sentences and paragraphs), introduce or highlight information, refer to something that was just mentioned, add a similar situation, or identify certain information as important.

Adversative Transitions

These terms and phrases distinguish facts, arguments, and other information, whether by contrasting and showing differences; by conceding points or making counterarguments; by dismissing the importance of a fact or argument; or replacing and suggesting alternatives.

Causal Transitions

These terms and phrases signal the reasons, conditions, purposes, circumstances, and cause-and-effect relationships. These transitions often come after an important point in the research paper has been established or to explore hypothetical relationships or circumstances.

Sequential Transitions

These transition terms and phrases organize your paper by numerical sequence; by showing continuation in thought or action; by referring to previously-mentioned information; by indicating digressions; and, finally, by concluding and summing up your paper. Sequential transitions are essential to creating structure and helping the reader understand the logical development through your paper’s methods, results, and analysis.

How to Choose Transitions in Academic Writing

Transitions are commonplace elements in writing, but they are also powerful tools that can be abused or misapplied if one isn’t careful. Here are some ways to ensure you are using transitions effectively.

• Check for overused, awkward, or absent transitions during the paper editing process. Don’t spend too much time trying to find the “perfect” transition while writing the paper.
• When you find a suitable place where a transition could connect ideas, establish relationships, and make it easier for the reader to understand your point, use the list to find a suitable transition term or phrase.
• Similarly, if you have repeated some terms again and again, find a substitute transition from the list and use that instead. This will help vary your writing and enhance the communication of ideas.
• Read the beginning of each paragraph. Did you include a transition? If not, look at the information in that paragraph and the preceding paragraph and ask yourself: “How does this information connect?” Then locate the best transition from the list.
• Check the structure of your paper—are your ideas clearly laid out in order? You should be able to locate sequence terms such as “first,” “second,” “following this,” “another,” “in addition,” “finally,” “in conclusion,” etc. These terms will help outline your paper for the reader.

For more helpful information on academic writing and the journal publication process, visit Wordvice’s  Academic Resources  Page. And be sure to check out Wordvice’s professional English editing services if you are looking for  paper editing and proofreading  after composing your academic document.

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Other Resources Around the Web

• MSU Writing Center.  Transition Words.
• UW-Madison Writing Center.  Transition Words and Phrases.

Transitions

What this handout is about.

In this crazy, mixed-up world of ours, transitions glue our ideas and our essays together. This handout will introduce you to some useful transitional expressions and help you employ them effectively.

The function and importance of transitions

In both academic writing and professional writing, your goal is to convey information clearly and concisely, if not to convert the reader to your way of thinking. Transitions help you to achieve these goals by establishing logical connections between sentences, paragraphs, and sections of your papers. In other words, transitions tell readers what to do with the information you present to them. Whether single words, quick phrases, or full sentences, they function as signs that tell readers how to think about, organize, and react to old and new ideas as they read through what you have written.

Transitions signal relationships between ideas—relationships such as: “Another example coming up—stay alert!” or “Here’s an exception to my previous statement” or “Although this idea appears to be true, here’s the real story.” Basically, transitions provide the reader with directions for how to piece together your ideas into a logically coherent argument. Transitions are not just verbal decorations that embellish your paper by making it sound or read better. They are words with particular meanings that tell the reader to think and react in a particular way to your ideas. In providing the reader with these important cues, transitions help readers understand the logic of how your ideas fit together.

Signs that you might need to work on your transitions

How can you tell whether you need to work on your transitions? Here are some possible clues:

• Your instructor has written comments like “choppy,” “jumpy,” “abrupt,” “flow,” “need signposts,” or “how is this related?” on your papers.
• Your readers (instructors, friends, or classmates) tell you that they had trouble following your organization or train of thought.
• You tend to write the way you think—and your brain often jumps from one idea to another pretty quickly.
• You wrote your paper in several discrete “chunks” and then pasted them together.
• You are working on a group paper; the draft you are working on was created by pasting pieces of several people’s writing together.

Organization

Since the clarity and effectiveness of your transitions will depend greatly on how well you have organized your paper, you may want to evaluate your paper’s organization before you work on transitions. In the margins of your draft, summarize in a word or short phrase what each paragraph is about or how it fits into your analysis as a whole. This exercise should help you to see the order of and connection between your ideas more clearly.

If after doing this exercise you find that you still have difficulty linking your ideas together in a coherent fashion, your problem may not be with transitions but with organization. For help in this area (and a more thorough explanation of the “reverse outlining” technique described in the previous paragraph), please see the Writing Center’s handout on organization .

How transitions work

The organization of your written work includes two elements: (1) the order in which you have chosen to present the different parts of your discussion or argument, and (2) the relationships you construct between these parts. Transitions cannot substitute for good organization, but they can make your organization clearer and easier to follow. Take a look at the following example:

El Pais , a Latin American country, has a new democratic government after having been a dictatorship for many years. Assume that you want to argue that El Pais is not as democratic as the conventional view would have us believe.

One way to effectively organize your argument would be to present the conventional view and then to provide the reader with your critical response to this view. So, in Paragraph A you would enumerate all the reasons that someone might consider El Pais highly democratic, while in Paragraph B you would refute these points. The transition that would establish the logical connection between these two key elements of your argument would indicate to the reader that the information in paragraph B contradicts the information in paragraph A. As a result, you might organize your argument, including the transition that links paragraph A with paragraph B, in the following manner:

Paragraph A: points that support the view that El Pais’s new government is very democratic.

Transition: Despite the previous arguments, there are many reasons to think that El Pais’s new government is not as democratic as typically believed.

Paragraph B: points that contradict the view that El Pais’s new government is very democratic.

In this case, the transition words “Despite the previous arguments,” suggest that the reader should not believe paragraph A and instead should consider the writer’s reasons for viewing El Pais’s democracy as suspect.

As the example suggests, transitions can help reinforce the underlying logic of your paper’s organization by providing the reader with essential information regarding the relationship between your ideas. In this way, transitions act as the glue that binds the components of your argument or discussion into a unified, coherent, and persuasive whole.

Types of transitions

Now that you have a general idea of how to go about developing effective transitions in your writing, let us briefly discuss the types of transitions your writing will use.

The types of transitions available to you are as diverse as the circumstances in which you need to use them. A transition can be a single word, a phrase, a sentence, or an entire paragraph. In each case, it functions the same way: First, the transition either directly summarizes the content of a preceding sentence, paragraph, or section or implies such a summary (by reminding the reader of what has come before). Then, it helps the reader anticipate or comprehend the new information that you wish to present.

• Transitions between sections: Particularly in longer works, it may be necessary to include transitional paragraphs that summarize for the reader the information just covered and specify the relevance of this information to the discussion in the following section.
• Transitions between paragraphs: If you have done a good job of arranging paragraphs so that the content of one leads logically to the next, the transition will highlight a relationship that already exists by summarizing the previous paragraph and suggesting something of the content of the paragraph that follows. A transition between paragraphs can be a word or two (however, for example, similarly), a phrase, or a sentence. Transitions can be at the end of the first paragraph, at the beginning of the second paragraph, or in both places.
• Transitions within paragraphs: As with transitions between sections and paragraphs, transitions within paragraphs act as cues by helping readers to anticipate what is coming before they read it. Within paragraphs, transitions tend to be single words or short phrases.

Transitional expressions

Effectively constructing each transition often depends upon your ability to identify words or phrases that will indicate for the reader the kind of logical relationships you want to convey. The table below should make it easier for you to find these words or phrases. Whenever you have trouble finding a word, phrase, or sentence to serve as an effective transition, refer to the information in the table for assistance. Look in the left column of the table for the kind of logical relationship you are trying to express. Then look in the right column of the table for examples of words or phrases that express this logical relationship.

Keep in mind that each of these words or phrases may have a slightly different meaning. Consult a dictionary or writer’s handbook if you are unsure of the exact meaning of a word or phrase.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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Transitional Words and Phrases

One of your primary goals as a writer is to present ideas in a clear and understandable way. To help readers move through your complex ideas, you want to be intentional about how you structure your paper as a whole as well as how you form the individual paragraphs that comprise it. In order to think through the challenges of presenting your ideas articulately, logically, and in ways that seem natural to your readers, check out some of these resources: Developing a Thesis Statement , Paragraphing , and Developing Strategic Transitions: Writing that Establishes Relationships and Connections Between Ideas.

While clear writing is mostly achieved through the deliberate sequencing of your ideas across your entire paper, you can guide readers through the connections you’re making by using transitional words in individual sentences. Transitional words and phrases can create powerful links between your ideas and can help your reader understand your paper’s logic.

In what follows, we’ve included a list of frequently used transitional words and phrases that can help you establish how your various ideas relate to each other. We’ve divided these words and phrases into categories based on the common kinds of relationships writers establish between ideas.

Two recommendations: Use these transitions strategically by making sure that the word or phrase you’re choosing matches the logic of the relationship you’re emphasizing or the connection you’re making. All of these words and phrases have different meanings, nuances, and connotations, so before using a particular transitional word in your paper, be sure you understand its meaning and usage completely, and be sure that it’s the right match for your paper’s logic. Use these transitional words and phrases sparingly because if you use too many of them, your readers might feel like you are overexplaining connections that are already clear.

Categories of Transition Words and Phrases

Causation Chronology Combinations Contrast Example

Importance Location Similarity Clarification Concession

Conclusion Intensification Purpose Summary

Transitions to help establish some of the most common kinds of relationships

Causation– Connecting instigator(s) to consequence(s).

accordingly as a result and so because

consequently for that reason hence on account of

since therefore thus

Chronology– Connecting what issues in regard to when they occur.

after afterwards always at length during earlier following immediately in the meantime

later never next now once simultaneously so far sometimes

soon subsequently then this time until now when whenever while

Combinations Lists– Connecting numerous events. Part/Whole– Connecting numerous elements that make up something bigger.

additionally again also and, or, not as a result besides even more

finally first, firstly further furthermore in addition in the first place in the second place

last, lastly moreover next second, secondly, etc. too

Contrast– Connecting two things by focusing on their differences.

after all although and yet at the same time but

despite however in contrast nevertheless nonetheless notwithstanding

on the contrary on the other hand otherwise though yet

Example– Connecting a general idea to a particular instance of this idea.

as an illustration e.g., (from a Latin abbreviation for “for example”)

for example for instance specifically that is

to demonstrate to illustrate

Importance– Connecting what is critical to what is more inconsequential.

chiefly critically

foundationally most importantly

of less importance primarily

Location– Connecting elements according to where they are placed in relationship to each other.

above adjacent to below beyond

centrally here nearby neighboring on

opposite to peripherally there wherever

Similarity– Connecting to things by suggesting that they are in some way alike.

by the same token in like manner

in similar fashion here in the same way

likewise wherever

Other kinds of transitional words and phrases Clarification

i.e., (from a Latin abbreviation for “that is”) in other words

that is that is to say to clarify to explain

to put it another way to rephrase it

granted it is true

naturally of course

finally lastly

in conclusion in the end

to conclude

Intensification

in fact indeed no

of course surely to repeat

undoubtedly without doubt yes

for this purpose in order that

so that to that end

to this end

in brief in sum

in summary in short

to sum up to summarize

Improving Your Writing Style

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Use the active voice

Put the action in the verb

Tidy up wordy phrases

Reduce wordy verbs

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Connecting Ideas Through Transitions

Using Transitional Words and Phrases

25 Best Transition Words for Providing Evidence

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Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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Transition words and phrases for providing evidence include “For example,”, “Evidence shows”, “A study found”, and “To demonstrate this point”.

These transition words and phrases can smooth the transition from one sentence to the next and help guide your reader, as shown below:

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. In fact, a 2021 literature review found that 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

If you have an entire paragraph dedicated to outlining evidence for your argument, you may want a transition word at the start of the paragraph (see examples) that indicates to your reader that you are about to provide evidence for statements made in a previous paragraph.

Shortlist of Transition Words for Evidence

• To illustrate this point…
• As can be seen in…
• To demonstrate,…
• Evidence of this fact can be seen in…
• Proof of this point is found in…
• For instance,…
• For one thing,…
• Compelling evidence shows…
• For a case in point, readers should look no further than…
• In fact, one study finds…
• New evidence has found…
• Evidence shows…
• In view of recent evidence,…
• Notably, one study found…
• A seminal study has found…
• According to…
• In the article…
• Three separate studies have found…
• Research indicates…
• Supporting evidence shows…
• As [Author] demonstrates…
• For example,…
• A study in 2022 found…
• This argument is supported by…
• A key report on this topic uncovered…

Read Also: 6 Best Ways to Provide Evidence in an Essay

Examples of Transitions to Evidence (in Context)

1. For example…

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. For example, a 2021 literature review found that 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

2. As [Author] demonstrates…

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. As Lynas et al. (2021) demonstrate, 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

3. Evidence suggests…

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. Evidence from a 2021 literature review suggests that 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

4. A study in 2021 found…

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. A study in 2021 found that 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

5. This argument is supported by…

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. This argument is supported by a comprehensive literature review in 2021 that found that 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021).”

Transition Words for Explaining Evidence

After you have provided your evidence, it is recommended that you provide a follow-up sentence explaining the evidence, its strength, and its relevance to the reader .

In other words, you may need a subsequent transition word that moves your reader from evidence to explanation.

Some examples of transition words for explaining evidence include:

• “This evidence shows…”
• “As shown above,”
• “The relevance of this point is”
• “These findings demonstrate”
• “This evidence compellingly demonstrates”
• “These findings suggest”
• “With this information, it is reasonable to conclude”

Examples of Transition Words for Explaining Evidence (in Context)

1. “This evidence shows…”

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. As Lynas et al. (2021) demonstrate, 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021). This evidence shows that governments should take climate change very seriously.”

2. “As shown above,”

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. As Lynas et al. (2021) demonstrate, 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021). As shown above, the evidence is compelling. Governments should take climate change very seriously.”

3. “The relevance of this point is”

“ The scientific community is nearly unanimous about the human-caused impacts of climate change. As Lynas et al. (2021) demonstrate, 99% of published scientific papers on climate change agree that humans have caused climate change (Lynas et al, 2021). The relevance of this point is that the time for debate is over. Governments should take climate change very seriously.”

Writing your Paragraph

I have a very simple structure for paragraphs. It’s as follows:

• Aim for 4 to 6 sentences per paragraph
• Use a topic sentence for the first sentence
• Follow up with transition phrases that help link the topic sentence to evidence and explanations that support your topic sentence.

Sometimes people call this the TEEL paragraph: topic, evidence, explanation, linking sentence.

It looks something like this:

For more on how I teach paragraphs, watch my YouTube video below:

(You can also take my essay writing course for all my tips and tricks on essay writing!)

Other Types of Transition Words

1. Emphasis

• “This strongly suggests”
• “To highlight the seriousness of this,”
• “To emphasize this point,”

2. Addition

• “In addition,”
• “Furthermore,”
• “Moreover,”
• “Additionally,”

3. Compare and Contrast

• “By contrast,”
• “However, other evidence contradicts this.”
• “Despite this,”

Go Deeper: Compare and Contrast Essay Examples

• “Firstly”, “secondly”, “thirdly”
• “Following on from the above point,”
• “Next”, “Then”, “Finally”

5. Cause and Effect

• “As a result,”
• “This has caused…”
• “Consequently,”
• “Because of this,”
• “Due to this,”
• “The result of this”

7. Illustration and examples

• “For example,”
• “To illustrate this point,”
• “An illustrative example is…”

8. Transitioning to conclusions

• “In conclusion”
• “This essay has demonstrated”
• “Given the compelling evidence presented in this essay,”

How many are Too many Transition Words?

I generally recommend between 1 and 3 transition words per paragraph, with an average of about 2.

If you have a transition word at the start of each and every sentence, the technique becomes repetitive and loses its value.

While you should use a transition whenever you feel it is necessary and natural, it’s worth checking if you’ve over-used certain words and phrases throughout your essay.

I’ve found the best way to see if your writing has started to sound unnatural is to read it out loud to yourself.

In this process, consider:

• Removing some Transition Words: If you identify a paragraph that has a transition word at the beginning of every single sentence, remove a few so you have one at the start of the paragraph and one in the middle of the paragraph – that’s all.
• Removing Overused Words: People tend to get a single word stuck in their head and they use it over and over again. If you identify overuse of a single word, it’s best to change it up. Consider some synonyms (like some of the words and phrases listed above) to add some more variety to your language.

Related: List of Words to Start a Paragraph

Overall, transition words that show evidence can help guide your reader. They allow you to tell a smooth and logical story. They can enhance the quality of your writing and help demonstrate your command of the topic.

When transitioning from an orientation sentence to your evidence, use transition words like “For example,” and “Evidence demonstrates” to link the two sentences or paragraphs.

• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd-2/ 10 Reasons you’re Perpetually Single
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Helpful Links

Here are sites with extensive lists of transition words and phrases:

  Transitional Words and Phrases – The Writing Center – UW–Madison (wisc.edu)   

Academic Phrasebank | Signalling transition (manchester.ac.uk)

Transitions – The Writing Center • University of North Carolina at Chapel Hill (unc.edu)

Transitions are words and/or phrases used to indicate movement or show change throughout a piece of writing. Transitions generally come at the beginning of a paragraph and can do the following:

• Alert readers of connections to, or further evidence for, the thesis
• Function as the topic sentence of paragraphs
• Guide readers through an argument
• Help writers stay on task

Transitions sentences often indicate or signal:

• Change to new topic
• Connection/flow from previous topic
• Continuity of overall argument/thesis

Transitions show connections between ideas. You must create these connections for the reader to move them along with your argument. Without transitions, you are building a house without nails. Things do not hold together.

Transition Words and Phrases

Transitions can signal change or relationship in these ways:

Time - order of events

Examples: while, immediately, never, after, later, earlier, always, soon, meanwhile, during, until now, next, following, once, then, simultaneously, so far

Contrast - show difference

Examples: yet, nevertheless, after all, but, however, though, otherwise, on the contrary, in contrast, on the other hand, at the same time

Compare - show similarity

Examples: in the same way, in like manner, similarly, likewise

Position - show spatial relationships

Examples: here, there, nearby, beyond, wherever, opposite to, above, below

Cause and effect

Examples: because, since, for that reason, therefore, consequently, accordingly, thus, as a result

Conclusion - wrap up/summarize the argument

Writing strong transitions often takes more than simply plugging in a transition word or phrase here and there. In a piece of academic writing, writers often need to use signposts, or transition sentences that signal the reader of connections to the thesis. To form a signpost, combine transition words, key terms from the thesis, and a mention of the previous topic and new topic.

Transition/signpost sentence structure: 

[Transition word/phrase] + [previous topic] + [brief restatement of or reference to thesis/argument] + [new topic]  = Signpost

• Do not think of this as a hard and fast template, but a general guide to what is included in a good transition.
• Transitions link the topic of the previous paragraph(s) to the topic of the present paragraph(s) and connect both to the overall goal/argument. You'll most often find signposts at the beginning of a paragraph, where they function as topic sentences .

Sample signpost using complimentary transition phrase:

According to [transition phrase] the same overall plan for first defeating Confederate forces in the field and then capturing major cities and rail hubs [overall thesis restated] that Grant followed by marching the Army of the Potomac into Virginia [previous topic] , Sherman likewise [transition word] advanced into Georgia to drive a dagger into the heart of the Confederacy [new topic] .

Contrasting ideas have the same essential format as complimentary but may use different transition words and phrases:

In contrast to [transition phrase] F.D.R., who maintained an ever-vigilant watchfulness over the Manhattan project [previous topic + reference to overall thesis] , Truman took over the presidency without any knowledge of the atomic bomb or its potential power [new topic] .

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4 Types of Transition Words for Research Papers 

Researchers often use transition words in academic writing to help guide the reader through text and communicate their ideas well. While these facilitate easy understanding and enhance the flow of the research paper, setting the wrong context with transition words in academic writing can disrupt tone and impact.

So how do you appropriately use transition words in research papers? This article explores the importance of using transitions in academic writing and explains the four types of transition words that can be used by students and researchers to improve their work.

Table of Contents

Why are transition words used in academic writing, additive transitions, adversative transitions, causal transitions, sequential transitions.

Transition words are the key language tools researchers use to communicate their ideas and concepts to readers. They not only reiterate the key arguments being made by the authors but are crucial to improving the structure and flow of the written language. Generally used at the beginning of sentences and paragraphs to form a bridge of communication, transition words can vary depending on your objective, placement, and structuring.

The four types of transition words in academic writing or research papers are additive transitions, adversative transitions, causal transitions, and sequential transitions. Let us look at each of these briefly below.

Types of Transition Words in Academic Writing

These types of transition words are used to inform or alert the reader that new or additional information is being introduced or added to something mentioned in the previous sentence or paragraph. Some examples of words in this category are – moreover, furthermore, additionally, and so on. Phrases like in fact, in addition to, considering this are examples of additive transition phrases that are commonly used.

Used to show contrast, offer alternative suggestions, or present counter arguments and differences, adversative transitions allow researchers to distinguish between different facts, or arguments by establishing or suggesting positions or alternatives opposing them. Examples of adversative transitions include, however, conversely, nevertheless, regardless, rather, and so on. Phrases like on the contrary, in any case, even though provide an adversative transition to arguments in a research paper.

By using causal transitions in their writing, authors can let readers know that there is a cause-and-effect relationship between two or more ideas or paragraphs. It is used to establish the key/important reasons, circumstances, or conditions of the argument being made or while studying hypothetical associations. Since, unless, consequently are some of the words in this type of transitions while in the event that, as a result are some of the causal phrases.

These transition words help to convey the continuation of a thought or action by a numerical sequence by alluding and referring to information or arguments that have been made earlier. Sequential transitions essentially bring order to the researcher’s main points or ideas in the research paper and help to create a logical outline to the arguments. These transition words and phrases essentially guide the reader through the research paper’s key methods, results, and analysis. Some examples of this type of transitions are initially, coincidentally, subsequently and so on. First of all, to conclude, by the way are a few examples of sequential transition phrases.

Researchers must carefully review their research paper, ensuring appropriate and effective use of transition words and phrases in academic writing. During the manuscript editing process, watch for transitions that may be out of context or misplaced. Remember, these words serve as tools to connect ideas and arguments, fostering logical and coherent flow in paragraphs. Double-check the necessity and accuracy of transitions at the beginning of sentences or paragraphs, ensuring they effectively bind and relate ideas and arguments. And finally, avoid repetition of the same transition words in your academic writing.

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Related Reads:

• How to Paraphrase Research Papers Effectively
• 3 Easy Ways for Researchers to Improve Their Academic Vocabulary
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What is a Descriptive Essay? How to Write It (with Examples)

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Research Paper Transition Examples

Searching for effective research paper transition examples? Learn how to make effective transitions between sections of a research paper. There are two distinct issues in making strong transitions:

• Does the upcoming section actually belong where you have placed it?
• Have you adequately signaled the reader why you are taking this next step?

The first is the most important: Does the upcoming section actually belong in the next spot? The sections in your research paper need to add up to your big point (or thesis statement) in a sensible progression. One way of putting that is, “Does the architecture of your paper correspond to the argument you are making?” Getting this architecture right is the goal of “large-scale editing,” which focuses on the order of the sections, their relationship to each other, and ultimately their correspondence to your thesis argument.

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It’s easy to craft graceful transitions when the sections are laid out in the right order. When they’re not, the transitions are bound to be rough. This difficulty, if you encounter it, is actually a valuable warning. It tells you that something is wrong and you need to change it. If the transitions are awkward and difficult to write, warning bells should ring. Something is wrong with the research paper’s overall structure.

After you’ve placed the sections in the right order, you still need to tell the reader when he is changing sections and briefly explain why. That’s an important part of line-by-line editing, which focuses on writing effective sentences and paragraphs.

Examples of Effective Transitions

Effective transition sentences and paragraphs often glance forward or backward, signaling that you are switching sections. Take this example from J. M. Roberts’s History of Europe . He is finishing a discussion of the Punic Wars between Rome and its great rival, Carthage. The last of these wars, he says, broke out in 149 B.C. and “ended with so complete a defeat for the Carthaginians that their city was destroyed . . . .” Now he turns to a new section on “Empire.” Here is the first sentence: “By then a Roman empire was in being in fact if not in name.”(J. M. Roberts, A History of Europe . London: Allen Lane, 1997, p. 48) Roberts signals the transition with just two words: “By then.” He is referring to the date (149 B.C.) given near the end of the previous section. Simple and smooth.

Michael Mandelbaum also accomplishes this transition between sections effortlessly, without bringing his narrative to a halt. In The Ideas That Conquered the World: Peace, Democracy, and Free Markets , one chapter shows how countries of the North Atlantic region invented the idea of peace and made it a reality among themselves. Here is his transition from one section of that chapter discussing “the idea of warlessness” to another section dealing with the history of that idea in Europe.

The widespread aversion to war within the countries of the Western core formed the foundation for common security, which in turn expressed the spirit of warlessness. To be sure, the rise of common security in Europe did not abolish war in other parts of the world and could not guarantee its permanent abolition even on the European continent. Neither, however, was it a flukish, transient product . . . . The European common security order did have historical precedents, and its principal features began to appear in other parts of the world. Precedents for Common Security The security arrangements in Europe at the dawn of the twenty-first century incorporated features of three different periods of the modern age: the nineteenth century, the interwar period, and the ColdWar. (Michael Mandelbaum, The Ideas That Conquered the World: Peace, Democracy, and Free Markets . New York: Public Affairs, 2002, p. 128)

It’s easier to make smooth transitions when neighboring sections deal with closely related subjects, as Mandelbaum’s do. Sometimes, however, you need to end one section with greater finality so you can switch to a different topic. The best way to do that is with a few summary comments at the end of the section. Your readers will understand you are drawing this topic to a close, and they won’t be blindsided by your shift to a new topic in the next section.

Here’s an example from economic historian Joel Mokyr’s book The Lever of Riches: Technological Creativity and Economic Progress . Mokyr is completing a section on social values in early industrial societies. The next section deals with a quite different aspect of technological progress: the role of property rights and institutions. So Mokyr needs to take the reader across a more abrupt change than Mandelbaum did. Mokyr does that in two ways. First, he summarizes his findings on social values, letting the reader know the section is ending. Then he says the impact of values is complicated, a point he illustrates in the final sentences, while the impact of property rights and institutions seems to be more straightforward. So he begins the new section with a nod to the old one, noting the contrast.

In commerce, war and politics, what was functional was often preferred [within Europe] to what was aesthetic or moral, and when it was not, natural selection saw to it that such pragmatism was never entirely absent in any society. . . . The contempt in which physical labor, commerce, and other economic activity were held did not disappear rapidly; much of European social history can be interpreted as a struggle between wealth and other values for a higher step in the hierarchy. The French concepts of bourgeois gentilhomme and nouveau riche still convey some contempt for people who joined the upper classes through economic success. Even in the nineteenth century, the accumulation of wealth was viewed as an admission ticket to social respectability to be abandoned as soon as a secure membership in the upper classes had been achieved. Institutions and Property Rights The institutional background of technological progress seems, on the surface, more straightforward. (Joel Mokyr, The Lever of Riches: Technological Creativity and Economic Progress . New York: Oxford University Press, 1990, p. 176)

Note the phrase, “on the surface.” Mokyr is hinting at his next point, that surface appearances are deceiving in this case. Good transitions between sections of your research paper depend on:

• Getting the sections in the right order
• Moving smoothly from one section to the next
• Signaling readers that they are taking the next step in your argument
• Explaining why this next step comes where it does

Return to writing a body of a research paper to see typical transition words and phrases.

Learn how to write a body of a research paper .

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Make Your Paragraphs Flow to Improve Writing

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Your written report, whether it is a creative, three-paragraph essay, or an extensive research paper , must be organized in a way that presents a satisfying experience for the reader. Sometimes it just seems impossible to make a paper flow—but that generally happens because your paragraphs aren’t arranged in the best possible order.

Two essential ingredients for a great-reading paper are logical order and smart transitions .

Create Flow With Better Paragraph Order

The first step toward creating flow is making sure your paragraphs are put together in a logical order. Many times, the first draft of a report or essay is a little choppy and out of sequence.

The good news about writing an essay of any length is that you can use "cut and paste" to rearrange your paragraphs. At first, this might sound terrifying: when you finish a draft of an essay it feels much like you have given birth—and cutting and pasting sounds scary. Don’t worry. You can simply use a practice version of your paper to experiment with.

Once you have finished a draft of your paper, save it and name it. Then make a second version by copying the entire first draft and pasting it into a new document.

• Now that you have a draft to experiment with, print it out and read it over. Do the paragraphs and topics flow in a logical order? If not, assign each paragraph a number and write the number in the margin. Don’t be at all surprised if you find that a paragraph on page three looks like it could work better on page one.
• Once you’ve numbered all the paragraphs, start cutting and pasting them in your document until they match your numbering system.
• Now, re-read your essay. If the order works better, you can go back and insert transition sentences between paragraphs.
• Finally, re-read both versions of your paper and confirm that your new version sounds better than the original.

Create Flow With Transition Words

Transition sentences (and words) are necessary for making connections between the claims, views, and statements you make in your writing. Transitions can involve a few words or a few sentences. If you can imagine your report as a quilt made up of many squares, you could think of your transition statements as the stitches that connect the squares. Red stitches might make your quilt ugly, while white stitching would give it flow.

For some types of writing, transitions can contain just a few simple words. Words like also, furthermore, and yet, can be used to connect one idea to another.

I had to walk two miles each morning to get to school. Yet , the distance was not something I considered a burden. I enjoyed walking to school when my friend Rhonda walked with me and talked about her travels. 

For more sophisticated essays, you’ll need a few sentences to make your paragraphs flow.

While the research was conducted at a university in Colorado, there is no evidence that altitude was considered to be a factor ... A similar exercise was carried out in the mountain state of West Virginia, where similar extremes of altitude exist.

You will find that it's easy to come up with effective transitions once your paragraphs are arranged in the most logical order.

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Writing Transitions

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Good transitions can connect paragraphs and turn disconnected writing into a unified whole. Instead of treating paragraphs as separate ideas, transitions can help readers understand how paragraphs work together, reference one another, and build to a larger point. The key to producing good transitions is highlighting connections between corresponding paragraphs. By referencing in one paragraph the relevant material from previous paragraphs, writers can develop important points for their readers.

It is a good idea to continue one paragraph where another leaves off. (Instances where this is especially challenging may suggest that the paragraphs don't belong together at all.) Picking up key phrases from the previous paragraph and highlighting them in the next can create an obvious progression for readers. Many times, it only takes a few words to draw these connections. Instead of writing transitions that could connect any paragraph to any other paragraph, write a transition that could only connect one specific paragraph to another specific paragraph.

In a short paper—even a research paper—you don’t need to provide an exhaustive summary as part of your conclusion. But you do need to make some kind of transition between your final body paragraph and your concluding paragraph. This may come in the form of a few sentences of summary. Or it may come in the form of a sentence that brings your readers back to your thesis or main idea and reminds your readers where you began and how far you have traveled.

So, for example, in a paper about the relationship between ADHD and rejection sensitivity, Vanessa Roser begins by introducing readers to the fact that researchers have studied the relationship between the two conditions and then provides her explanation of that relationship. Here’s her thesis: “While socialization may indeed be an important factor in RS, I argue that individuals with ADHD may also possess a neurological predisposition to RS that is exacerbated by the differing executive and emotional regulation characteristic of ADHD.”

In her final paragraph, Roser reminds us of where she started by echoing her thesis: “This literature demonstrates that, as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Highlight the “so what”  

At the beginning of your paper, you explain to your readers what’s at stake—why they should care about the argument you’re making. In your conclusion, you can bring readers back to those stakes by reminding them why your argument is important in the first place. You can also draft a few sentences that put those stakes into a new or broader context.

In the conclusion to her paper about ADHD and RS, Roser echoes the stakes she established in her introduction—that research into connections between ADHD and RS has led to contradictory results, raising questions about the “behavioral mediation hypothesis.”

She writes, “as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Leave your readers with the “now what”  

After the “what” and the “so what,” you should leave your reader with some final thoughts. If you have written a strong introduction, your readers will know why you have been arguing what you have been arguing—and why they should care. And if you’ve made a good case for your thesis, then your readers should be in a position to see things in a new way, understand new questions, or be ready for something that they weren’t ready for before they read your paper.

In her conclusion, Roser offers two “now what” statements. First, she explains that it is important to recognize that the flawed behavioral mediation hypothesis “seems to place a degree of fault on the individual. It implies that individuals with ADHD must have elicited such frequent or intense rejection by virtue of their inadequate social skills, erasing the possibility that they may simply possess a natural sensitivity to emotion.” She then highlights the broader implications for treatment of people with ADHD, noting that recognizing the actual connection between rejection sensitivity and ADHD “has profound implications for understanding how individuals with ADHD might best be treated in educational settings, by counselors, family, peers, or even society as a whole.”

To find your own “now what” for your essay’s conclusion, try asking yourself these questions:

• What can my readers now understand, see in a new light, or grapple with that they would not have understood in the same way before reading my paper? Are we a step closer to understanding a larger phenomenon or to understanding why what was at stake is so important?  
• What questions can I now raise that would not have made sense at the beginning of my paper? Questions for further research? Other ways that this topic could be approached?  
• Are there other applications for my research? Could my questions be asked about different data in a different context? Could I use my methods to answer a different question?  
• What action should be taken in light of this argument? What action do I predict will be taken or could lead to a solution?  
• What larger context might my argument be a part of?  

What to avoid in your conclusion  

• a complete restatement of all that you have said in your paper.  
• a substantial counterargument that you do not have space to refute; you should introduce counterarguments before your conclusion.  
• an apology for what you have not said. If you need to explain the scope of your paper, you should do this sooner—but don’t apologize for what you have not discussed in your paper.  
• fake transitions like “in conclusion” that are followed by sentences that aren’t actually conclusions. (“In conclusion, I have now demonstrated that my thesis is correct.”)
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Using Transition Words for Research Papers that Exceed Expectations

Transition words for research papers.

When students write research papers, they tend to become hyper-focused on research, factual accuracy, and proving their thesis. This great. After all, these are all very important in a research paper. Unfortunately, this leaves the matter of writing style neglected in many cases. One area that is neglected the most is proper use of transition words for research papers. Research paper transition words are words and phrases that you can use to move from one idea to the next, to show a connection between two ideas, or to contrast two ideas. Transition words can be used as a means to move from one paragraph into another, or within a single paragraph. If transition words and phrases are not used, or if they are used incorrectly, your research paper will have a very choppy and awkward feel to it when others attempt to read it.

Using Transition Words Effectively

Research papers are all about getting information to the readers. Transition words and phrases are tools that you can use to get that information onto the page in a way that is as readable as possible. The best way to use transition words and phrases is to think about what you want to do with the information that you have. For example, are you adding details to an idea or support to a fact? Are you moving from one idea to the next? Are you preparing to present some information that contradicts your current idea? Basically, you use transition words and phrases to do the following:

• Show the passage of time

Use words and phrases such as next, before, after, first, second, third, then, a while later, or finally

• To summarize

Use words and phrases such as in other words, in summary, to repeat, or, in brief

• To contrast and compare

Use words and phrases like in contrast, in comparison, however, like, unlike, or on the other hand

Use words and phrases like furthermore, as evidence shows, proving, or since.

• To add to an idea

Use words and phrases such as also, next, in addition to that, or furthermore

• To show an exception

Use words and phrases such as however, but, except, or never the less

• To shift focus to a new idea

Use words and phrases like moving forward, next, or another thing to consider

• To demonstrate with an example

Try using words and phrases such as for example, to demonstrate, consider this, or for instance

Read also: Where to get instant research paper writing help ? 

Focusing on Organization

When organization must really be the focus transitions are key. If you are trying to write a well-organized research paper, transition words and phrases are your friend. You can use them to smoothly transition from paragraph to the next, and from one point to the next. If you are having a difficult time using transition words, you may wish to resequence some of your ideas and paragraphs so that they are better organized.

Moving Beyond Transitions

As established, you must use transition words for organization and readability. There are however other things to be considered when writing a research paper. For example, if you need to generate  interesting research paper ideas , you can look at some of the other blog posts at grabmyessay.com for some fresh ideas. If you need advice on using citations in each work that you produce , you can ask your instructor for clarification on what they want you to do. Finally, if you need professional writing help, you can contact grabmyessay.com, one of the best writing services for college research papers on the internet today.

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Andy Preisler

I’m Andy Preisler, and I’m super happy to be joining the blog team at GrabMyEssay.com!

While I hail from Fayetteville, Arkansas (I know, not the most progressive state!), I left the Southern life behind me many years ago when I went to college for my first degree. I’ve received it in University of Arkansas, Fayetteville and I’m really proud of this. Since then, I have studied in the U.S., and later on, continued my education in Loughborough University, UK, where I actually my second Bachelor’s Degree along the way.

With my perpetual studies (my parents wonder if it will ever stop), I have become a bit of an expert on college life – academic, social, and financial – and love sharing my experiences and my methods of “circumventing the system” with others.  I will be sharing all of these great tips and strategies with my readers, so stay tuned!

When I am not blogging or enrolling in some new course that interests me, I am backpacking through Europe and staying in hostels, working on my second novel (a riveting murder mystery), and pursuing my interest in music. Yes, I travel with my guitar, and you would be amazed at the amount of cash I can accumulate, just performing on the streets of European cities (they are so much more tolerant of vagabond musicians). 

My other passion is environmental. In my short 27 years of life on this planet, I have witnessed the extinction of species, the destruction of rain forests, and irreparable harm to our oceans. I contribute both time and money to several international environmental organizations, because we all must do our part to save Mother Earth.

But I digress! If you are interested in the “ins and outs” of college life, and want some great tales of navigating through the game of “degree attainment,” as well as tips for easing the pain of those pesky essay and paper assignments, follow my blog!

I would love to hear from you, to give you advice, and to lend a listening ear. You can contact me at  [email protected]  anytime! And follow my posts – you won’t be disappointed!

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How to Write a Research Paper | A Beginner's Guide

A research paper is a piece of academic writing that provides analysis, interpretation, and argument based on in-depth independent research.

Research papers are similar to academic essays , but they are usually longer and more detailed assignments, designed to assess not only your writing skills but also your skills in scholarly research. Writing a research paper requires you to demonstrate a strong knowledge of your topic, engage with a variety of sources, and make an original contribution to the debate.

This step-by-step guide takes you through the entire writing process, from understanding your assignment to proofreading your final draft.

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Table of contents

Understand the assignment, choose a research paper topic, conduct preliminary research, develop a thesis statement, create a research paper outline, write a first draft of the research paper, write the introduction, write a compelling body of text, write the conclusion, the second draft, the revision process, research paper checklist, free lecture slides.

Completing a research paper successfully means accomplishing the specific tasks set out for you. Before you start, make sure you thoroughly understanding the assignment task sheet:

• Read it carefully, looking for anything confusing you might need to clarify with your professor.
• Identify the assignment goal, deadline, length specifications, formatting, and submission method.
• Make a bulleted list of the key points, then go back and cross completed items off as you’re writing.

Carefully consider your timeframe and word limit: be realistic, and plan enough time to research, write, and edit.

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There are many ways to generate an idea for a research paper, from brainstorming with pen and paper to talking it through with a fellow student or professor.

You can try free writing, which involves taking a broad topic and writing continuously for two or three minutes to identify absolutely anything relevant that could be interesting.

You can also gain inspiration from other research. The discussion or recommendations sections of research papers often include ideas for other specific topics that require further examination.

Once you have a broad subject area, narrow it down to choose a topic that interests you, m eets the criteria of your assignment, and i s possible to research. Aim for ideas that are both original and specific:

• A paper following the chronology of World War II would not be original or specific enough.
• A paper on the experience of Danish citizens living close to the German border during World War II would be specific and could be original enough.

Note any discussions that seem important to the topic, and try to find an issue that you can focus your paper around. Use a variety of sources , including journals, books, and reliable websites, to ensure you do not miss anything glaring.

Do not only verify the ideas you have in mind, but look for sources that contradict your point of view.

• Is there anything people seem to overlook in the sources you research?
• Are there any heated debates you can address?
• Do you have a unique take on your topic?
• Have there been some recent developments that build on the extant research?

In this stage, you might find it helpful to formulate some research questions to help guide you. To write research questions, try to finish the following sentence: “I want to know how/what/why…”

A thesis statement is a statement of your central argument — it establishes the purpose and position of your paper. If you started with a research question, the thesis statement should answer it. It should also show what evidence and reasoning you’ll use to support that answer.

The thesis statement should be concise, contentious, and coherent. That means it should briefly summarize your argument in a sentence or two, make a claim that requires further evidence or analysis, and make a coherent point that relates to every part of the paper.

You will probably revise and refine the thesis statement as you do more research, but it can serve as a guide throughout the writing process. Every paragraph should aim to support and develop this central claim.

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A research paper outline is essentially a list of the key topics, arguments, and evidence you want to include, divided into sections with headings so that you know roughly what the paper will look like before you start writing.

A structure outline can help make the writing process much more efficient, so it’s worth dedicating some time to create one.

Your first draft won’t be perfect — you can polish later on. Your priorities at this stage are as follows:

• Maintaining forward momentum — write now, perfect later.
• Paying attention to clear organization and logical ordering of paragraphs and sentences, which will help when you come to the second draft.
• Expressing your ideas as clearly as possible, so you know what you were trying to say when you come back to the text.

You do not need to start by writing the introduction. Begin where it feels most natural for you — some prefer to finish the most difficult sections first, while others choose to start with the easiest part. If you created an outline, use it as a map while you work.

Do not delete large sections of text. If you begin to dislike something you have written or find it doesn’t quite fit, move it to a different document, but don’t lose it completely — you never know if it might come in useful later.

Paragraph structure

Paragraphs are the basic building blocks of research papers. Each one should focus on a single claim or idea that helps to establish the overall argument or purpose of the paper.

Example paragraph

George Orwell’s 1946 essay “Politics and the English Language” has had an enduring impact on thought about the relationship between politics and language. This impact is particularly obvious in light of the various critical review articles that have recently referenced the essay. For example, consider Mark Falcoff’s 2009 article in The National Review Online, “The Perversion of Language; or, Orwell Revisited,” in which he analyzes several common words (“activist,” “civil-rights leader,” “diversity,” and more). Falcoff’s close analysis of the ambiguity built into political language intentionally mirrors Orwell’s own point-by-point analysis of the political language of his day. Even 63 years after its publication, Orwell’s essay is emulated by contemporary thinkers.

Citing sources

It’s also important to keep track of citations at this stage to avoid accidental plagiarism . Each time you use a source, make sure to take note of where the information came from.

You can use our free citation generators to automatically create citations and save your reference list as you go.

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The research paper introduction should address three questions: What, why, and how? After finishing the introduction, the reader should know what the paper is about, why it is worth reading, and how you’ll build your arguments.

What? Be specific about the topic of the paper, introduce the background, and define key terms or concepts.

Why? This is the most important, but also the most difficult, part of the introduction. Try to provide brief answers to the following questions: What new material or insight are you offering? What important issues does your essay help define or answer?

How? To let the reader know what to expect from the rest of the paper, the introduction should include a “map” of what will be discussed, briefly presenting the key elements of the paper in chronological order.

The major struggle faced by most writers is how to organize the information presented in the paper, which is one reason an outline is so useful. However, remember that the outline is only a guide and, when writing, you can be flexible with the order in which the information and arguments are presented.

One way to stay on track is to use your thesis statement and topic sentences . Check:

• topic sentences against the thesis statement;
• topic sentences against each other, for similarities and logical ordering;
• and each sentence against the topic sentence of that paragraph.

Be aware of paragraphs that seem to cover the same things. If two paragraphs discuss something similar, they must approach that topic in different ways. Aim to create smooth transitions between sentences, paragraphs, and sections.

The research paper conclusion is designed to help your reader out of the paper’s argument, giving them a sense of finality.

Trace the course of the paper, emphasizing how it all comes together to prove your thesis statement. Give the paper a sense of finality by making sure the reader understands how you’ve settled the issues raised in the introduction.

You might also discuss the more general consequences of the argument, outline what the paper offers to future students of the topic, and suggest any questions the paper’s argument raises but cannot or does not try to answer.

You should not :

• Offer new arguments or essential information
• Take up any more space than necessary
• Begin with stock phrases that signal you are ending the paper (e.g. “In conclusion”)

There are four main considerations when it comes to the second draft.

• Check how your vision of the paper lines up with the first draft and, more importantly, that your paper still answers the assignment.
• Identify any assumptions that might require (more substantial) justification, keeping your reader’s perspective foremost in mind. Remove these points if you cannot substantiate them further.
• Be open to rearranging your ideas. Check whether any sections feel out of place and whether your ideas could be better organized.
• If you find that old ideas do not fit as well as you anticipated, you should cut them out or condense them. You might also find that new and well-suited ideas occurred to you during the writing of the first draft — now is the time to make them part of the paper.

The goal during the revision and proofreading process is to ensure you have completed all the necessary tasks and that the paper is as well-articulated as possible. You can speed up the proofreading process by using the AI proofreader .

Global concerns

• Confirm that your paper completes every task specified in your assignment sheet.
• Check for logical organization and flow of paragraphs.
• Check paragraphs against the introduction and thesis statement.

Fine-grained details

Check the content of each paragraph, making sure that:

• each sentence helps support the topic sentence.
• no unnecessary or irrelevant information is present.
• all technical terms your audience might not know are identified.

Next, think about sentence structure , grammatical errors, and formatting . Check that you have correctly used transition words and phrases to show the connections between your ideas. Look for typos, cut unnecessary words, and check for consistency in aspects such as heading formatting and spellings .

Finally, you need to make sure your paper is correctly formatted according to the rules of the citation style you are using. For example, you might need to include an MLA heading  or create an APA title page .

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Checklist: Research paper

I have followed all instructions in the assignment sheet.

My introduction presents my topic in an engaging way and provides necessary background information.

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Discussion paper: The socioeconomic implications of the transition

2024-10-08T17:40:00+01:00

An analytical framework for a whole-of-government approach to a just transition

The recent backlash against the net-zero transition, and the policies aimed at achieving it, have brought in stark clarity the importance of accounting for the social effects of the transition, both in terms of socio-economic conditions, and of the protection of fundamental rights.

With this paper, the PRI explores in more detail how social issues could inform a whole-of-government policy approach to the economic transition. It presents an analytical framework aimed at supporting policy makers in identifying potential negative impacts, promoting effectiveness across all segments of transition policy reform, and securing broad-based support for the economic transition.

The research adopts a broad approach to the analysis of the stakeholders of the transition, to include all parts of society which ultimately may be affected or have a role to play.

This paper builds on research and interviews with experts from civil society, academia, international organisations, and PRI signatories. It is a starting point rather than a definitive solution, which can also inform investor engagement with policymakers on social issues related to the transition.

The policy approaches we present as part of this research aim to lay a foundation for placing people at the centre of the climate transition, managing the competing interests inherent to this transition, and setting a course for future work in this area.

We welcome feedback on this discussion paper from PRI Signatories and policy stakeholders. Please address your comments to [email protected] .

Download the discussion paper in full below.

Socioeconomic implications of the economic transition: Discussion paper

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Implementing a Medicines at Transitions Intervention (MaTI) for patients with heart failure: a process evaluation of the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial

• Catherine Powell 1 , 2 ,
• Hanif Ismail 3 ,
• Liz Breen 1 , 2 , 4 ,
• Beth Fylan 1 , 2 , 4 ,
• Sarah L Alderson 5 ,
• Chris P Gale 6 , 7 , 8 ,
• Peter Gardner 1 , 2 ,
• Jonathan Silcock 1 , 2 ,
• Bonnie Cundill 9 ,
• Amanda Farrin 9 ,
• Ellen Mason 9 ,
• Lauren Moreau 9 ,
• David P Alldred 10 &

ISCOMAT Programme Management Team

BMC Health Services Research volume  24 , Article number:  1210 ( 2024 ) Cite this article

Metrics details

Heart failure is a major global health challenge incurring a high rate of mortality, morbidity and hospitalisation. Effective medicines management at the time of hospital discharge into the community could reduce poor outcomes for people with heart failure. Within the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) programme, the Medicines at Transitions Intervention (MaTI) was co-designed to improve such transitions, with a cluster randomised controlled trial to test effectiveness. The MaTI includes a patient toolkit and transfer of discharge medicines information to community pharmacy. This paper aims to determine the degree to which the intervention was delivered, and identify barriers and facilitators experienced by staff for the successful implementation of the intervention.

The study was conducted in six purposively selected intervention sites. A mixed-methods design was employed using hospital staff interviews, structured and unstructured ward observations, and routine trial data about adherence to the MaTI. A parallel mixed analysis was applied. Qualitative data were analysed thematically using the Framework method. Data were synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research (CFIR).

With limited routines of communication between ward staff and community pharmacy, hospital staff found implementing community pharmacy-related steps of the intervention challenging. Staff time was depleted by attempts to bridge system barriers, sometimes leading to steps not being delivered. Whilst the introduction of the patient toolkit was often completed and valued as important patient education and a helpful way to explain medicines, the medicines discharge log within it was not, as this was seen as a duplication of existing systems. Within the CFIR the most applicable constructs were identified as ‘intervention complexity’ and ‘cosmopolitanism’ based on how well hospitals were networked with community pharmacies, and the availability of hospital resources to facilitate this.

The MaTI was generally successfully implemented, particularly the introduction of the toolkit. However, implementation involving community pharmacy was more challenging and more effective communication systems are needed to support wider implementation.

Trial registration

11/04/2018 ISRCTN66212970. https://www.isrctn.com/ISRCTN66212970 .

Peer Review reports

Contributions to the literature

Enhances our understanding of the key barriers and facilitators experienced by staff that may be present in implementing a complex intervention across a transition involving hospital and community pharmacy

Illustrates the application of the CFIR in a mixed method process evaluation using interviews with patients and hospital staff, and observations

Twenty-six million people globally live with heart failure, with 900,000 people affected in the United Kingdom and numbers rising [ 1 ]. Heart failure can be managed through pharmacological treatments, such as angiotensin-converting enzyme (ACE) inhibitors, beta adrenoceptor antagonists and diuretics [ 2 ]. When medicines are effectively optimised, rates of hospitalisation decrease; and quality of life and mortality rates improve [ 3 ]. However, achieving optimisation can be challenging when patients living with heart failure frequently transition between hospital and home, and readmission rates can be as high as 50% [ 4 ]. A key issue in transitions is the poor communication of treatment between health care professionals [ 5 ]. Therefore, creating effective communication systems when patients with heart failure are discharged from hospital is essential.

The Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) programme aimed to improve the use of prescribed medicines when patients with heart failure are discharged from hospital. A Medicines at Transitions Intervention (MaTI) was co-designed with healthcare professionals and patients, and consisted of a patient held ‘My Medicines Toolkit’ in booklet format. The toolkit included: (1) My Healthcare Team, with contact details of their healthcare team; (2) My Medicines Checklist to help manage medicines; (3) Managing My Medicines, with information about the patient’s medicines, side effects and how to take them; (4) Managing my Symptoms, ‘traffic lights’ to help patients monitor changes to their symptoms of worsening heart failure and know when they should seek help; and a pull-out sheet for hospital staff to complete medicines information and enabling patients to monitor their condition.

The discharge medicines list was transferred (by post, facsimile, or electronically depending on site preference) by the hospital to the community pharmacy to facilitate medicines reconciliation. Community pharmacists were encouraged to invite patients for a medicines discussion or Medicines Use Review (MUR) [ 6 ]. Hospital staff were provided with face-to-face and online training and supporting materials, including an implementation guide and a script to introduce the toolkit to patients. Figure 1 indicates how MaTI is delivered through 7 steps by hospital staff.

Medicines at Transitions Intervention (MaTI) 7 steps

Following feasibility testing, [ 7 ] intervention effectiveness was assessed in a cluster randomised controlled trial (cRCT) in NHS trusts in England over 12 months, with a recruitment target of 50 patients per site (2100 patients total) [ 8 ]. 44 clusters were randomised, of which 43 opened to recruitment. Alongside the trial, a process evaluation was conducted. To identify implementation determinants we selected the Consolidated Framework for Implementation Research (CFIR) as an appropriate framework to guide our analysis during and post-implementation [ 9 ]. We have previously published patient experiences of the MaTI. This paper focuses on intervention implementation by hospital staff [ 10 ].

The key objectives were to:

Determine the degree to which the intervention was delivered

Identify barriers and facilitators experienced by staff for the successful implementation of the intervention

The study design was a parallel mixed synthesis study using quantitative and qualitative data from six intervention sites of the total 43 recruiting clusters in the cRCT. We have previously published the protocol [ 11 ]. Methods involved non-participant observations, semi-structured interviews and analysing trial fidelity data on adherence to MaTI. We intended to interview hospital staff involved in the intervention, such as nurses, pharmacists, pharmacy technicians, and site coordinators (research nurses at each site), as well as community pharmacists, and community heart failure nurses [ 11 ]. However due to the health and social implications of the COVID-19 pandemic and the prioritisation of COVID-19 research [ 12 ], we were required to adapt our approach.

Our Patient Led Steering Group has been involved throughout the ISCOMAT programme on key aspects such as facilitating the intervention co-design process and co-analysing patient interviews. For further information on the Patient Led Steering group see Powell et al. (2021) [ 13 ]. The trial and process evaluation received approval by Research Ethics Committee and the UK Health Research Authority REC: 18/YH/0017/IRAS: 231 431. This study is reported according to the consolidated criteria for reporting qualitative research [ 14 ] (See Additional File 1).

Sampling and recruitment

We purposively sampled six intervention sites using three criteria: university and non-university hospitals, the method for transferring medicines discharge information to community pharmacists (e.g., an electronic system such as PharmOutcomes ® [ 15 ]), and geographical location (see Additional file 2 for site characteristics). Explanations of differences between sites have been provided to effectively apply the CFIR, revealing differences in barriers and facilitators to implementing the intervention.

Permission was sought from each site to conduct non-participant ward-level observations, and staff were provided with information sheets and could opt out if they wished. A script for informing patients of the researchers’ presence was supplied. Interviewees were identified during ward observations and from site coordinators. Informed consent was obtained from all the participants. Procedures for recruiting patients to the cRCT are outlined in the trial protocol [ 8 ].

Data collection

Once sites had implemented the intervention for at least 6 months, observations of clinical staff and interactions with patients were conducted over 2.5 hours at each process evaluation site by female (CP) and male (HI) researchers. The observations focused on the discharge process, introduction of the My Medicines Toolkit (the Toolkit), and ward culture. Observations were structured, focusing on the intervention delivery; and unstructured, focusing on ward culture (see Additional files 3 and 4 for data collection tools). Community pharmacy data were sought from pharmacies through surveys (see Additional file 5).

Once trial recruitment was complete in sites, semi-structured interviews with hospital staff were conducted using an interview schedule by experienced qualitative researcher HI. The schedule was informed by the CFIR, covering staff experiences in delivering the intervention (see Additional file 6). Interviews lasting approximately 45 minutes were audio recorded and transcribed verbatim. The timing of interviews was designed to ensure we did not influence implementation during the trial. In Site 2, interviews were conducted 2 weeks post-trial recruitment as planned. In the other sites, interviews were conducted several months later in August/September 2020 after all sites had closed to trial recruitment due to COVID-19.

Data analysis

Data for this process evaluation were analysed prior to main trial analysis to reduce bias in our interpretation. A two-stage approach to qualitative analysis was conducted by two researchers. First, Framework analysis was applied to interviews and unstructured observations, identifying barriers and facilitators to implementation [ 16 , 17 ].

Framework analysis involved 7 key stages. In stage 1 audio recordings of interviews were transcribed verbatim by a transcription company. Stage 2 involved familiarisation with data, where all data were read, and relevant notes made in the margins. In stage 3 data were coded applying an inductive approach. Stage 4 involved developing a working analytical framework, where CP and HI agreed on codes for subsequent data collection. In stage 5 CP and HI organised data into the analytical framework. Stage 6 involved charting data into the framework matrix. Summaries were created from data and charted onto the CFIR by site and intervention steps [ 9 ]. We applied the competing values framework to understand the ‘culture’ domain within sites [ 18 , 19 ]. We added additional constructs of person-centred care and safety which were considered appropriate for a medicines management intervention in a hospital setting. The competing values framework was applied to collated observation and interview data. Decisions on the appropriate constructs were agreed by researchers CP and HI. In stage 7 data were interpreted.

Patient interviews were co-analysed with researchers CP, HI and the ISCOMAT patient led steering group. Qualitative staff data were analysed by CP and HI. The thematic analysis was iterative with regular discussions taking place with the process evaluation team.

All qualitative analysis was conducted using NVivo 12 [ 20 ]. A project template with CFIR construct and domain names were directly imported into NVivo via the CFIR website [ 21 ].

Quantitative data including structured observations were descriptively analysed (see Additional file 7). Additional data from the wider trial were triangulated with process evaluation data to inform, contextualise, and explain findings. These included a Site Feasibility Questionnaire (questions to assess sites eligibility), MaTI checklist completed in the hospital (monitors adherence to intervention components), and a community pharmacy data collection form (assessed implementation within community pharmacy).

A parallel mixed analysis was applied to qualitative and quantitative data, with both independently analysed, and integrated using meta-inferences [ 22 ]. Data were integrated through applying the CFIR. All CFIR constructs and domains were considered in the analysis.

Structured and unstructured observations of up to 2.5 hours with breaks, were conducted separately, each by two researchers. Unstructured observations were conducted in six sites, and one structured observation was conducted by two researchers in five of the sites. Eleven staff interviewees were recruited, with no dropouts. Table 1 indicates the types of staff recruited by site. Some CFIR constructs were not relevant or had little evidence to support their relevance. Table 2 shows the domains and constructs that were relevant in explaining barriers and facilitators to implementation.

The figures below indicate the degree to which the intervention was delivered. Figures 2 and 3 illustrate the extent to which each step was completed per returned MaTI checklist form for each patient. Figure 2 outlines fidelity across all intervention sites, and Fig. 3 indicates fidelity across process evaluation sites. Qualitative analysis on completion of the MaTI is outlined in ‘Process, executing’ domain of the CFIR analysis.

Routine trial data indicated that in all sites, checklist in patients notes/box (Step 1), identify community pharmacist (Step 2a) and toolkit introduction (Step 3) were most frequently implemented. This was reflected in the six process evaluation sites, apart from the toolkit introduction (Step 3) in Site 2, with relatively low intervention fidelity (65.2%). Completion of medicines discharge log (Step 4) was the least completed step across all sites. In the process evaluation sites, Site 1 completion of medicines discharge log (Step 4) was completed for only 38.3% of patients. Contact community pharmacist (Step 2b) had relatively low completion overall (64.6%), and this was reflected in process evaluation sites Site 2 (38.3%) and Site 6 (27.4%). However, relatively high completion of contact community pharmacist (Step 2b) was evidenced across process evaluation sites Site 5 (80%), Site 4 (87.5%), Site 3 (86.7%) and Site 1 (90.0%). Check community pharmacist received information (Step 7) in Site 3 was an outlier with only 6.7% completion, relatively low when compared with all sites (63.2%).

All intervention sites fidelity to MaTI (of 593 forms received)

Process evaluation sites fidelity to MaTI (of forms received)

Hospital staff reported information transfer to community pharmacy (Step 6) had a relatively high completion rate of 68% across all sites, and at least 73% competition in process evaluation sites, however community pharmacy survey data suggested otherwise.

Across all sites, 124 community pharmacy surveys were returned. 75/124 (60.4%) community pharmacists reported not receiving discharge information, and data were missing for 12/124 (9.6%). Of those 75, the information transfer to community pharmacy (Step 6) was reported as completed by hospital staff for 71 (94.6%) patients.

Across process evaluation sites, 75 community pharmacy surveys were returned (Site 1:24, Site 2:30, Site 3:6, Site 4:8, Site 5:2, Site 6:5). Of those, the information transfer to community pharmacy (Step 6) was completed for 64/75 (Site 1:24, Site 2:29, Site 3:4, Site 4:8, Site 5:2, Site 6:5). However, only 22/75 community pharmacists reported receiving information from the hospital, with 46 community pharmacists reporting they did not receive it, and 7 forms had missing data.

Table 2 presents barriers and facilitators to the intervention implementation by CFIR domain and constructs. Data were drawn from staff interviews, and structured and unstructured observations. These provided insight into the routine trial data.

Intervention characteristics domain

Each domain was defined as ‘distinguishing’ (influence differentiation in implementation), or not. Intervention characteristics was not a highly distinguishing domain, with adaptability and intervention design having positive impacts on implementation, and intervention complexity presenting limitations to implementation. Data sources ‘interviews’, ‘observations’ and ‘surveys’ are outlined as subheadings below.

Facilitators

Interview data.

Adaptability was an important construct, with MaTI adaptable across all sites. MaTI was adapted to differing information transfer systems, staff roles, family and patient involvement, and ethos.

Site 1 trained ward staff to use PharmOutcomes ® to transfer of discharge medicines information, [ 15 ] whereas in Site 3, pharmacists used PharmOutcomes ® , [ 15 ] perhaps reflecting their approach of pharmacists driving the intervention in Site 3.

“We just sort of told [the ward staff] how to get into [PharmOutcomes ® [ 15 ]] set the patient up on there , and then how to just transfer information , with a user guide.” Site 1 Ward pharmacist.

The design and quality of the toolkit was well regarded across all sites. It was felt to have benefited staff and patients. Staff found it helped them discuss medicines with patients. The presentation was thought to be very appealing in structure, colour and style,

“ it was more glossier and more colourful version of the booklets they used to have…they found that useful yes to explain…very appreciative of the amount of information in it and how easy it is for the patients.” Site 2 Coordinator.

The complexity of the intervention was important for implementation across most sites. Completion of the medicines discharge log (Step 4) could be challenging where last-minute medicine changes were made (Site 6), or during out-of-hours when coordinators were not available to support staff (Site 1). Site 2 provided the discharge summary in the back of the toolkit as a work around to completing Step 4, given the lack of time at discharge.

“we didn’t fill them out if I’m honest , we didn’t just because it was time-consuming; that was the only thing. But what we did do is we put the discharge summary in the back.” Site 2 Cardio nurse.

Outer setting domain

The outer setting was a distinguishing construct, despite limited mention of external factors having an influence on implementation; with some sites demonstrating prioritisation of patient need and adopting differing approaches to toolkit delivery in relation to such needs.

Staff were motivated to deliver intervention components when they felt they addressed patient needs. This domain was also relevant to compatibility as staff held values and beliefs which facilitated implementation. Patient education was regarded as important for supporting patients to continue monitoring and understanding their medicines.

“There’s such a high rate of patients coming back into hospital , so this is really important to educate patients so they can monitor themselves at home.” Site 2 Ward nurse.

Staff adapted toolkit delivery according to perceived patient engagement and knowledge of heart failure.

“Somebody who is proactive , it is then beneficial to them…Patients who just said they didn’t want to take part…we still left information for them , it’s their choice.” Site 1 coordinator.

Some evidence suggested changes in pharmacist practice and education supported intervention delivery with pharmacists expected to have a greater role discussing medicines with patients.

Cosmopolitism (how well networked the organisation is), was an important construct. Communication between hospital and community pharmacy posed significant challenges. Contact community pharmacist (Step 2b), information transfer to community pharmacy (Step 6) and check community pharmacy received information (Step 7) were challenging to implement.

Survey data

Community pharmacies were not prepared to receive information from hospitals and lacked knowledge of ISCOMAT. Limited community pharmacy data indicated some had difficulty understanding ‘medicines reconciliation’. Occasionally only locum and relief pharmacists were available, thus staff who originally received the study letter were not available.

Sites sometimes needed to spend significant time and resource to complete these steps.

“It was more trying…to get them [community pharmacy] confirmation that they’d received it [Discharge medicines information]. ” Site 4 Site coordinator.

“The pharmacy…didn’t have an NHS.net account , so they couldn’t send patient identifiable data across , so that was the biggest stumbling block and on some occasions we even just hand delivered it…so that we knew it had gone securely.” Site 4, Heart failure specialist nurse.

“Just getting , trying to get hold of the one [pharmacist] that was on shift when the letter arrived , and getting them to remember…what part of the letter we spoke about.” Site 6.

Community pharmacists were deemed to be more responsive if communicating with a hospital pharmacist.

“Coming from a pharmacist to a pharmacist , I think they would probably acknowledge things a little bit better and a bit quicker…There were only a couple of pharmacies that would reply and go , “Yes , got it.” Site 4.

Site 3 reported fewer communication issues with community pharmacy using their existing PharmOutcomes ® [ 15 ] systems via hospital pharmacists; however, despite having this in place, they only checked community pharmacists received information (Step 7) for 6.7% of patients.

Inner setting domain

The inner setting was not a highly distinguishing construct. However, some sites were more able to readily implement the intervention according to staff role and availability. All constructs had a strong influence on implementation.

Networking and communication had a strong positive influence on implementation at all sites (excluding Site 5 where no data were available).

The intervention steps were delivered over a lengthy period, which required sites to develop effective network and communication systems to work around staff availability. The extract below illustrates how some steps of the intervention were organised between different staff.

“The heart failure team…basically said to all the other nursing staff or doctors on the ward ‘Let us know if you see a heart failure patient but we’ll kind of take over…that was the most efficient… isn’t a process where you do it all at once , you’re kind of identifying , giving the information.” Site 3 Hospital pharmacist.

The implementation climate had a positive influence on implementation across Sites 6, 2, 1, and 3. The implementation climate had a negative impact in Site 4, and to some extent in Site 5 based on limited data. Compatibility and relative priority of the intervention were key factors influencing implementation.

Other intervention steps were less distinguishing in terms of compatibility, with sites describing providing patient education as the norm, and the toolkit enhanced this to some extent.

“For the majority of… [patients], it…reinforced the discussions that we normally have at discharge , about their medication , but probably it was definitely more in depth.” Site 6 Site coordinator.

The lack of available resources was a hinderance across most sites. Having the appropriate staff available on the ward to deliver the intervention could enhance implementation for different phases of MaTI. Two of the lesser implemented steps of MaTI, communication with community pharmacy and completion of the medicines discharge log (Step 4), were impacted by this.

Leadership engagement had some positive influence in Site 2, but this was offset by available resources which led to a strong negative influence on implementation. The intervention in Site 2 was eventually only delivered to trial patients, as opposed to all eligible patients on the ward as planned.

“for the first half of the trial we did [ Step 6 ] for all the patients , but it was very difficult to catch up with that turnover”. Site 2 Coordinator.

Available resources were relevant to whether staff prioritised intervention steps, particularly Step 4. Sites took different approaches to organising staff to introduce the toolkit (Step 3). Site 3 felt having only those with heart failure training delivering the toolkit was most appropriate, whereas Site 6 felt non-heart failure specialist staff could implement the intervention, with strong leadership support to increase their confidence.

“We decided that we didn’t want non-heart failure members of the team explaining…I did extra training myself…how to break the news…for a newly qualified Band 6 pharmacist…it’s quite a big ask.” Site 3 Pharmacist.

In Site 4, hospital heart failure nurses were also community heart failure nurses. Usual practice as part of this role involved providing existing medicines information to patients in hospital and continuing to speak with patients in community settings. Patients received both this existing information and the toolkit. The nurse was sceptical as to whether the patients were using the toolkit once they returned home.

“…we see… [patients] in the community after discharge and…I’ve yet to have anybody show me their toolkit.” Site 4 Heart failure specialist nurse.

Characteristics of individuals

Data were available for ‘knowledge and beliefs about the intervention’ and ‘other personal attributes.’ For example, staff reported some patients felt the intervention was already being undertaken in community pharmacies. Some site coordinators discussed the importance of their ability to increase staff confidence and sense of self-efficacy in delivering MaTI.

In Site 4, staff members found communication with community pharmacies difficult, and in one example overcame this by personally delivering information to the pharmacy.

The process of implementation was a distinguishing domain, particularly in terms of planning, participant engagement, and executing the intervention.

There was limited evidence of sites planning for MaTI, however it was a distinguishing concept as some sites appeared to have taken more measures to prepare than others. Site 3 had developed a standard operating procedure to ensure effective implementation of using PharmOutcomes ® [ 15 ] to transfer information. Training was described as important to prepare staff for MaTI implementation in Site 1 and Site 6.

Levels of engagement varied across the sites, involving formally appointed internal implementation leaders (site coordinators), champions (specific individuals driving forward implementation), key stakeholders (ward staff), and innovation participants (patients). Key distinctions between sites included lesser engagement of ward staff in Site 1 and Site 2, site coordinator lesser involvement in Site 3, and variation in methods of engaging patients with the toolkit. See additional file 2 for more information on staff implementation roles.

Observation data

Site coordinators were engaged in intervention delivery across all sites; however, the level to which they engaged varied. In sites Site 2 and Site 1, the site coordinators had high levels of activity in both delivering the intervention themselves and organising other staff members. Site 3 was an outlier as it was primarily led by pharmacists.

Educational/career backgrounds and recognising value in the intervention may have influenced site coordinator engagement.

As the site coordinator in Site 6 highlighted;

“[It’s] really important , really good for… [patients]. Any education is , so they can have self-awareness and ownership of the management of the illness…I can’t see any drawbacks.” Site 6 Coordinator.

Pharmacists were champions in Site 2 and Site 3, facilitating implementation. Observations in Site 2 revealed the pharmacy technician taking a pivot role, locating themselves centrally in the ward and coordinating with ward staff to deliver the toolkit, and communicating with patients and staff to identify the community pharmacist.

In Site 3, the pharmacist led the intervention and described how the site coordinator supported them in doing so. The pharmacist was highly motivated to educate patients, describing their training as a reason for understanding the importance of this. Champions were engaged with steps involving communication with community pharmacy, despite challenges such as duplication of effort.

Ward staff engagement could be challenging and varied over time. Staff engaged with the toolkit introduction in all but one site where staff engagement deteriorated (Site 1).

Across most sites, ward staff were less involved in steps related to contact with community pharmacy, Site 1 differed as they were trained in the use of PharmOutcomes ® [ 15 ] to transfer information to community pharmacy. Training and leadership were important ways of engaging staff, particularly for sites more negative in the compatibility construct. In Site 6 the coordinator described engaging staff through creating a supportive team culture.

“It was mainly the staff nurses and the Deputy Sister that delivered it…all of the nurses at some point , there are probably only a couple of them on the ward that actually didn’t do any delivery of the toolkit…we tried to do it together as a team.” Site 6 Coordinator.

Task allocation could help engagement. In Site 2 tasks were clearly allocated to different staff members, however this took time to implement. Ward staff lack of engagement led site coordinators to become responsible to deliver more of the intervention than they had capacity for in some sites (Site 2, Site 1).

Patient engagement was thought to vary according to patients’ individual characteristics, such as number of changes to medicines. However, through structured observations we identified variation in how staff engaged patients.

Full and detailed explanations were provided in some sites. One toolkit introduction involved staff discussing all sections of the toolkit. In over half of cases, we observed patients’ questions being answered by staff. Although some patients had no questions, staff encouraged questions in only one observation. Informing patients of medicines information being sent to the community pharmacist was completed in all but one observation. The MUR or medicines discussion invitation was either not mentioned at all or mentioned very briefly. Emphasising the toolkit’s utility could enhance patient engagement, however some toolkit sections were given greater importance than others.

“Heart failure specialist nurse…explains the link between pharmacy hospital and GP and how it can break down. Shows toolkit… 4 sections all are important, but 1 and 4 more important, 2 and 3 less so… Meds Checklist and managing meds – says patients really like this section.” Site 5 Qualitative observation.

We observed the toolkit introduced in stages at some sites (Site 3, Site 4). In Site 3 the patient was gradually introduced to the toolkit, with two staff members before and after lunch, and then it was left with the patient who was encouraged to look at it with a family member. Body language also differed across sites. Some staff members were standing above patients whilst introducing them to the toolkit (Site 1, Site 4) whereas in other cases staff members sat at eye level with the patient (Site 3, Site 5, Site 6).

“The nurse who first spoke to the patient knelt to be at eye level with the patient , smiled and regularly touched the patient’s hand. The patient had trouble seeing and the nurse adjusted the lighting in the room. The pharmacist who gave more detail about the toolkit later engaged with the patient in a similar way , pointing out sections of the toolkit.” (Site 3 Observation).

Engaging with patients through encouraging questions and listening happened in some cases but less so in others. The pace by which the toolkit was introduced limited patient opportunities for questions in some instances.

“A little hurried, did not always wait for patient to respond…Ended with asking patient if any questions please ask.” (Site 4 Observation).

We have used fidelity measures, as outlined in Figs. 2 and 3 , to assess the degree to which MaTI was accomplished.

Implementation across process evaluation sites

The distinguishing CFIR domains above provide insight into why sites implemented the intervention differently, highlighting key barriers and facilitators. An interpretation of these findings for each site is provided below.

Site 1 had one of the highest levels of implementation. Planning for how much staff could achieve without the need for the site coordinator to be constantly present seemed to make a key difference. Moreover, the introduction of the toolkit (step 3) was close to their usual practice which meant that the site coordinator’s presence was not constantly needed. Thus the implementation climate also had an impact as the staff were more receptive to the intervention. Contacting community pharmacists (Step 2b) and Information transfer to community pharmacy (Step 6) were facilitated by ward staff being trained by a pharmacist in the electronic transfer of information using PharmOutcomes ® . Therefore, ward staff were able to complete this without supervision. However, lack of staff engagement and intervention complexity were distinguishing features in lower levels of completion of the discharge log (Step 4). The reduced engagement in ward staff meant staff coordinators had to be present to drive this aspect of implementation which explains why Step 4 not consistently completed out-of-hours when coordinators were unavailable to support staff.

Site 2 had the lowest levels of completion for contacting the community pharmacist (Step 2b) and toolkit introduction (Step 3). Readiness for implementation particularly had a negative impact on the opportunity to implement the intervention. The site coordinator at site 2 was highly motivated to deliver the intervention and engage staff, with the outer setting characteristic of deeming the intervention as meeting patient needs and resources influencing this. However, ward staff engagement appeared limited. The coordinator described a lack of resource to deliver the intervention as planned, implying a lack of readiness for implementation.

Similar to other sites, intervention characteristics were a barrier as completing the discharge medicines log (Step 4) was seen as duplication of existing practice and therefore the site’s routine discharge summary was used instead of the discharge log (Step 4).

In Site 3 planning and ability were important with standard operating procedures (SOPs) developed, yet it was the lowest implementer for patient told of referral to community pharmacy (Step 5 (63%), information transfer to community pharmacy (step 6) (73%) and check community pharmacist received information (step 7) (6.7%), As with site 1, PharmOutcomes ® . was used, suggesting that the use of PharmOutcomes ® alone was not sufficient to ensure the success of communication with community pharmacy, although information transfer to community pharmacy (Step 6) was completed for the majority of patients. Evidence was limited as to why check community pharmacist received information (Step 7) was not well implemented at site 3, however one key distinction from site 1 (which completed Step 7 well) was that the site coordinator was less involved in site 3. Potentially this additional coordinator input could have supported implementation where the SOP and PharmOutcomes ® were not sufficient. Contacting the same community pharmacist following initial contact (Step 2b) was described across sites in general as challenging, and perhaps the site coordinator could have helped to ensure check community pharmacist received information (Step 7) was achieved.

The intervention was pharmacist-driven in Site 3, and the delivery of Step 3 was by pharmacists and nurses trained in heart failure as a specialism. Introduction of the toolkit (Step 3) was highly implemented (93%), and our observations confirmed the quality of delivery of step 3 - it was person-centred and shared effectively between appropriate staff members. Thus, the inner setting, communication, resources, and positive working culture within site 3 had an impact on Step 3 implementation.

Site 4 had higher levels of implementation relative to other process evaluation sites across the seven steps, although Inform patients they have been referred to their community pharmacist (Step 5) was slightly less implemented at (67%). The implementation climate (cosmopolitism) was a barrier to implementation. Poor communication with community pharmacy presented a significant challenge, however staff members described making additional efforts of physically visiting the community pharmacies themselves. This may have partly been due to the lack of involvement from hospital pharmacists in this site as highlighted by nursing staff as a barrier to communicating with community pharmacists. Again, as in sites 1 and 2, the site coordinator was the key individual driving the intervention forward.

A nurse reported that patients may have accessed other information sources other than the toolkit post discharge. Thus, the compatibility and relative priority of the intervention seemed to be a barrier to implementation.

In site 5, the intervention was delivered by nurses and a pharmacist. Data from site 5 were limited to observations and surveys. Survey data indicated the intervention was well implemented relative to other process evaluation sites. Our observations confirmed the implementation of step 3. However qualitative observation data revealed that some sections of the toolkit may have been more thoroughly emphasised than other parts.

In one observation, the toolkit introduction primarily focused on the staff members ‘preferred’ sections of the toolkit, with the staff member highlighting to the patient that they disliked the ‘My Medicines’ section of the toolkit.

“Heart failure specialist nurse…shows toolkit… 4 sections all are important but 1 and 4 more important 2 and 3 less so… Medicines Checklist and managing medicines – says patients really like this section.” Site 5 Qualitative Observation.

Thus, patient engagement may have been higher on some sections of the intervention than others.

Site 6 had significant challenges contacting community pharmacy in particular, and were the second lowest performing site for contacting the community pharmacist (step 2b), information transfer to community pharmacy (step 6) and check community pharmacist received information (step 7). The implementation climate (cosmopolitism) was a key barrier to this, with identifying and speaking to the correct community pharmacist an additional barrier. The inner setting, readiness for implementation, was a strength with the site coordinator describing the importance of strong leadership for implementation.

Intervention complexity was a barrier across sites. Completing the discharge medicines log (step 4) was the least completed step as it was felt to be a duplication of existing documents. Contacting community pharmacy (step 2b), information transfer to community pharmacy (step 6), and check community pharmacy received information (step 7), were a key area of distinction across sites. The implementation climate (cosmopolitism) appeared to be a barrier across sites for these steps. Sites were not well networked with community pharmacy for the purposes of the intervention. The community pharmacy perspective from different sites was unclear as there were limited data from community pharmacy surveys, and community pharmacy interviews were not completed due to the COVID-19 pandemic. However, there were indications overall that community pharmacists were not aware of the intervention, despite being provided with it.

The distinction between sites appears to be their differing approaches to circumventing this barrier. The method of transfer itself may have been a less distinguishing factor than CFIR constructs ‘readiness for implementation’, the amount of resource that sites had, ‘individual characteristics’ of different types of ward staff, and ‘process’ planning through training staff members. For example, Site 4 were relatively successful as they had ward staff physically visiting community pharmacies, site 2 struggled as staff felt there was insufficient resource and therefore became less engaged, and site 3 had less site coordinator presence.

Core MaTI steps were generally delivered as intended across process evaluation sites. Steps that relied only on hospital staff to complete required tasks (Steps 1,2a,3,5 and 6) were completed more frequently than those requiring contacting community pharmacy (Steps 2b, 6 and 7). However, Completion of medicines discharge log (Step 4), was implemented relatively less frequently across sites. Barriers and facilitators to implementation were identified through all CFIR domains and several constructs. However, the most important constructs were intervention complexity, cosmopolitanism (organisation networked), and the available resources organisations had. Hospitals and community pharmacies lacked pre-existing systems of communication which led to difficulties completing steps which relied on this.

The patient toolkit was valued and frequently introduced, with variation in its introduction. However, the medicines discharge log was often not completed, and seen as a duplication of existing systems. Both the log and community pharmacy related steps placed pressure on staff time.

There were distinctions between sites. Some sites were more able to address the challenges associated with communication with community pharmacy as staff were highly motivated, they had effective leadership and resources. However, the higher level of implementation shown by the survey data at some sites such as Site 4 may not be sustainable. High implementers site 4 were physically visiting pharmacies to transfer the information as communication was poor. In Site 1, contact community pharmacist (Step 2b) appeared to be facilitated by site coordinator presence. Thus, how much longer staff would be able to continue such practices is questionable. The CFIR analysis provided an indication of the quality of implementation, in addition to barriers and facilitators to implementation. Our analysis of patient interviews revealed how the MaTI could potentially enable patients to increase medicines knowledge, be alerted to seek help, communicate more effectively with health care professionals, provide information, support existing care, and support systems and be reassured when professional support was unavailable. However, patients were less able to benefit from these enhancements where they faced issues with design and delivery of the toolkit, as well as sources of support available to them within the community [ 10 ]. The toolkit delivery was inconsistent, with some staff members missing sections, and not always taking time to effectively engage with the patient. The Capability, Opportunity and Motivation COM-B model suggests that for someone to engage in a behaviour they must be physically and psychologically capable to use opportunities through motivators [ 23 ]. Staff may be lacking opportunity to engage patients through lack of resource. Moreover, ward pharmacists may have had more capability and opportunity to communicate with community pharmacists where communication systems were already in place. Effective collaboration between hospital and community pharmacists can help to establish continuity of care.

Implications for policy and practice

Whilst the analysis did indicate the benefit of personalising the toolkit according to patient need, greater guidance around the toolkit introduction may be necessary when implementing the intervention, particularly on a wider scale. We know from patient interviews that the quality of delivery makes a significant difference to patient experiences, impacting on whether patients feel the toolkit is important to engage with, or what the role of community pharmacy is [ 10 ].

From an implementation perspective, the lack of receptiveness from community pharmacy led to hospital staff investing more resources to refer patients and send discharge information. Thus, sustainable implementation relies on developing greater engagement with community pharmacy. When the intervention was designed, community pharmacy involvement was considered. We wished to understand how the intervention could work in a real world setting within existing commissioned services. Moreover, it was necessary to ensure control sites were not contaminated by exposing community pharmacies to the intervention, which may have theoretically activated them to intervene. Therefore, it was decided that community pharmacies first contact would be by the hospital with a cover letter at the point of discharge. We could not therefore work with community pharmacies to resolve usages of different electronic systems. For the intervention to be transferable across settings, existing practices and systems across primary and secondary care need to be considered [ 24 , 25 , 26 , 27 ]. Despite steps being carried out in Site 4, positive impacts of implementation may have been reduced because of the competing information providing by the heart failure specialist nurse who was a community heart failure nurse. It may potentially be difficult to implement ISCOMAT in other systems in Europe. However, there is important learning from our innovative practice which may be learnt from or applied.

Strengths and limitations

Our strengths include using a mixed methods approach. Multiple key data sources were collated before the impact of the COVID-19 pandemic. The toolkit introduction (Step 3), a vital step of the intervention, was explored fully, revealing the importance of ‘process’ for the MaTI’s implementation, as the hospital observations provided rich data. However, a structured observation was not completed in Site 2, as it was not possible to know in advance when the toolkit would be introduced to patients, and due to geographical distance, it was not possible for researchers to respond quickly. We were able to conduct most hospital staff interviews despite the COVID-19 pandemic, which were crucial in helping us to identify and explore barriers and facilitators to implementation. Protocol changes due to the COVID-19 pandemic included the reduction in hospital staff interviews from 30 to 11, 2 community pharmacy interviews where 10 were planned, 4 process evaluation community pharmacy surveys, and no community heart failure nurse surveys collated where a maximum of 30 were planned. The limited number of process evaluation community pharmacy interviews and surveys were not analysed. Only the evaluation stage was affected by the COVID-19 pandemic. Implementation of the intervention at process evaluation sites ended prior to the pandemic. All observation of implementation and patient interviews were conducted prior to the pandemic. Staff interviews were completed prior to and during the pandemic about events prior to the pandemic.

Trial survey data from community pharmacies for process evaluation sites were collated prior to the pandemic. Community pharmacy survey data from non-process evaluation sites were collected both prior to the pandemic and during the pandemic. It was a study limitation that community pharmacies could not have been given more notice of their potential role in the post discharge process with medication reconciliation and MUR. However, we wished to understand how the intervention could work in a real world setting and ensure control sites were not contaminated. It was also a study limitation that data were not collated about any differences in the types of community pharmacy, which could potentially exist.

Our study was limited to six process evaluation sites which reduces generalisability. However, we were able to recruit a diverse sample of sites based on key characteristics that could influence implementation including a range of university and non-university hospitals, differing methods for transferring medicines discharge information to community pharmacists and covering different geographic areas of England. Moreover, fidelity data were collected for all intervention sites.

Applying an inductive approach to analysis risked confirmation bias. One of the researchers involved in the process evaluation (HI) had also been heavily involved in implementing the intervention. However, the results were agreed by both CP and HI and confirmed with the wider research team. We planned to utilise the CFIR purely for analysis purposes, which is common practice across implementation studies. However, we acknowledge that the process may have been enhanced by applying the CFIR more extensively during earlier study phases, such as assessing sites pre-implementation or employing a scoring system as advocated by Damschroder et al. (2013) had there been more extensive data. Our pre-Covid-19 plan had been to collect survey data from hospital staff, community pharmacists and heart failure nurses, as well as interviews with community pharmacists and site 5 staff, but this was not possible. Consequently, the analysis was based on less data than originally planned. Moreover, unfortunately we were not able to observe specific policies or organisational directives that made discharge easier at one site than another. Thus, some domains may have been more or less distinguishing.

The MaTI was relatively well implemented with hospital staff completing intervention steps. However, steps involving community pharmacy were more challenging to implement. Key facilitators included staff motivation to deliver the intervention when it was felt to meet patients’ needs. Patient education was regarded as important for supporting patients to continue monitoring and understanding their medicines. Barriers were identified including the interventions complexity, how well hospitals were networked with community pharmacies and availability of hospital resources.

The findings from this study will support an explanation of the main trial findings when available. Community pharmacy and hospitals need more effective systems of communication to allow safe transfer of medicines information at transitions of care; thus, system level issues need to be addressed to support the wider implementation if the MaTI is shown to be effective.

Availability of data and materials

All data requests should be submitted to the corresponding author for consideration and would be subject to review by a subgroup of the team. Access to anonymised data may be granted following this review. All data-sharing activities would require a data-sharing agreement.

Abbreviations

Medicines at Transition Intervention

Consolidated Framework for Implementation Research

Medicines Use Review

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Acknowledgements

We would like to thank Alison Blenkinsopp, Gerry Armitage, Jan Speechley, Renuka Salvi, the ISCOMAT Patient-led Steering Group, and the ISCOMAT Trial and Programme Management Groups. For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from publication from this submission. 

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ISCOMAT Programme Management Team: Powell C, Ismail H, Breen L, Fylan B, Alderson S, Gale C, Gardner P, Silcock J, Cundill B, Farrin A, Mason E, Alldred D, Armitage G, Blenkinsopp A, Turner R, Taylor A, Kellar I, Hartley S, Moreau L, Bojke C, Wright J.

This study is funded by the National Institute for Health Research (NIHR) (Programme Grants for Applied Research [Grant Reference Number RP‐PG‐0514‐20009]). This study was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC).

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All authors revised the manuscript critically for important intellectual content and made substantial contributions to conception and design. CP drafted the manuscript. All authors have given final approval for the version to be published (CP, HI, LB, BF, SA, CG, PG, JS, BC, AF, EM, LM, DA).

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Powell, C., Ismail, H., Breen, L. et al. Implementing a Medicines at Transitions Intervention (MaTI) for patients with heart failure: a process evaluation of the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial. BMC Health Serv Res 24 , 1210 (2024). https://doi.org/10.1186/s12913-024-11487-x

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The role of geographic distances in green industrial pilot policies evaluation: A sustainability transition perspective

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• Published: 10 October 2024

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• Chen Luyi 1 ,
• Chang Yue 2 &
• Ruan Xinhui 3 , 4  

Green industrial policies (GIPs) aim to promote the adoption of green technology within a sustainability framework. While previous evaluations of GIP have focused more on the policy itself and the impacts within the policy boundaries, this paper further introduces the geographical factor to analyze the impact of different spatial geographic distances on implementing GIP. By integrating geographic distances into a spatial difference-in-differences analysis to assess the effects of municipal green industry policies (referred to as green industry pilot policies in this paper) enacted in 11 cities in China from 2006 to 2010, we find that these policies not only improve environmental and economic outcomes in targeted regions but also have spillover effects that may affect neighboring areas negatively, highlighting the importance of geographic considerations. The effectiveness of green industrial policies varies across cities, influenced by local socio-technical systems and regional characteristics such as infrastructure and information technology. These findings suggest that policy impacts are complex and multifaceted, requiring a comprehensive understanding of geographic interdependencies. By incorporating geographic factors, this research contributes to sustainability transition theory by offering insights into the spatial and temporal dynamics of socio-technical systems. The results underscore the need for policymakers to consider spatial-temporal aspects and potential secondary effects on adjacent regions when designing and implementing green industrial policies.

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The data that support the findings of this study are available on request from the corresponding author, upon reasonable request.

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Acknowledgements

The authors would like to especially express thanks to Prof. Yun Zhao for his help in the manuscript revision and replenishment.

This work was supported by the National Natural Science Foundation of China (Grant Numbers: 72074132, 71704165); Soft Science Research Project of Shandong Province (2022RZA07023); and Qingdao Strategic Research Plan Project Results (23–2-7-zlyj-10-zhc).

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Ruan Xinhui

State Key Lab of Clean Energy Utilization, State Environmental Protection Engineering Center for Coal-Fired Air Pollution Control, Zhejiang University, 38 Zheda Road, Hangzhou, 310027, People’s Republic of China

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Conceptualization: Luyi Chen, Yue Chang, Xinhui Ruan; data curation: Luyi Chen, Yue Chang; methodology: Luyi Chen, Yue Chang; software: Luyi Chen, Xinhui Ruan; writing—original draft: Luyi Chen, Yue Chang; writing—review and editing: Luyi Chen, Yue Chang; funding acquisition: Luyi Chen; resources: Luyi Chen, Yue Chang; supervision: Luyi Chen.

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Chen, L., Chang, Y. & Ruan, X. The role of geographic distances in green industrial pilot policies evaluation: A sustainability transition perspective. Environ Sci Pollut Res (2024). https://doi.org/10.1007/s11356-024-35199-1

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Received : 25 October 2023

Accepted : 26 September 2024

Published : 10 October 2024

DOI : https://doi.org/10.1007/s11356-024-35199-1

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