Building bridges from different settings to a common ground – Strengthening transitions for older patients with multiple chronic conditions: A qualitative descriptive design

Abstract

The role of transitional care nurses is sparsely described and knowledge is needed on their specific tasks and responsibilities to ensure continuity in transitions for older patients with multiple chronic conditions. The aim of this study was to explore and describe transitional care nurses’ practices related to transitional trajectories of older patients with multiple chronic conditions, to gain an insight into their experiences of their role and tasks. Twelve transitional care nurses from hospital and municipality settings participated in focused participant observations and/or group interviews from January to February 2021. The study was reported in line with the COREQ guidelines. A thematic analysis revealed the overarching theme of ‘Building bridges from different settings to a common ground’, supported by three parallel sub-themes. To ensure safe transitions between hospital and home for older patients, collaboration and communication must be strengthened between the health sectors.

Understanding Facilitators and Challenges to Care Transition in Cardiac Rehabilitation: Perspectives and Assumptions of Healthcare Professionals

“…This is supported in the literature stating that the biopsychosocial perspective is a central part of rehabilitation in general and a core skill for healthcare professionals in rehabilitation should be to adapt to the patient’s social context (Wade, 2020a, 2020b). Previous studies have found that collaboration and coordination between hospital and community healthcare services can be challenged due to different policies, cultures and approaches toward the patients (Møller et al, 2022; Petersen et al, 2019). Despite the collaboration being seen as important and overall well-functioning, the challenges experienced by the community-based healthcare professionals may be explained by different cultures and approaches in the two settings.…”

“…Close collaboration and efficient communication between hospital and community healthcare services may thus ensure a more smooth transition for both patients and healthcare professionals (Coleman & Berenson, 2004;Møller et al, 2022).…”

“…The transition from hospital to community healthcare services may, however, be challenging, and information may be lost, misinterpreted or distorted increasing the risk of patient drop-out of CR (Philibert & Barach, 2012; Sommer et al, 2022). Collaboration across settings may be challenged due to different policies, work environments and cultures in each setting, insufficient systems to transfer information between the settings, and missing information in discharge letters (Lyngsø et al, 2016; Møller et al, 2022; Petersen et al, 2019). Close collaboration and efficient communication between hospital and community healthcare services may thus ensure a more smooth transition for both patients and healthcare professionals (Coleman & Berenson, 2004; Møller et al, 2022).…”

“…Collaboration across settings may be challenged due to different policies, work environments and cultures in each setting, insufficient systems to transfer information between the settings, and missing information in discharge letters (Lyngsø et al, 2016; Møller et al, 2022; Petersen et al, 2019). Close collaboration and efficient communication between hospital and community healthcare services may thus ensure a more smooth transition for both patients and healthcare professionals (Coleman & Berenson, 2004; Møller et al, 2022).…”