Building bridges from different settings to a common ground - Transitional care nurses’ practices to strengthen trajectories between hospital and home for older patients with multiple chronic conditions

Introduction: The population of older patients with multiple chronic conditions is increasing worldwide and the patients’ care transitions between hospital and home is often complicated by multiple contacts to the healthcare system. Transitional care nurses are employed in the Region of Zealand, Denmark, to ensure continuity in the older patients’ transitions and to reduce adverse events and re-admissions. However, the specific tasks and responsibilities of the transitional care nurses’ role is left undescribed, leaving the transitional care nurses with unprecise directions to perform their work.Aim and methods: The aim of this study was to explore and describe the transitional care nurses’ practices related to transitions between hospital and home of older patients with multiple chronic conditions, to gain insight into their experiences of their role and tasks, and how it could be strengthened.A qualitative constructivist design was used. Thirteen transitional care nurses employed in hospital and municipality settings participated in focused participant observations (n=12) and/or in two group interviews (n=5) in February 2021. Data were analysed using thematic analysis as described by Braun and Clarke.Key Findings: The thematic analysis revealed the overarching theme of “Building bridges from different settings to a common ground” and three sub-themes: 1) “Practice depends on the setting” describing how the transitional care nurses were employed in different positions and settings in hospital or municipality care. This entailed different responsibilities and work areas, and created differences in the transitional care nurses’ role, although they shared a common goal for transitional care. 2) “Building external and internal bridges” describing how transitional care nurses’ worked to improve patient transitions between hospital and home (external collaboration), as well as cooperating with other health professionals within their organizations (internal coordination). 3) “Towards a common ground” describing ...