Continuity of Care during Care Transition: Nurses’ Experiences and Challenges

The aim of this study was to gain increased knowledge about nurses’ experiences of care transition of older patients from hospital to municipal health care, based on two research questions: How is nurses’ experience continuity during care transition of older patients from hospital to municipal health care? How would nurses describe an optimal care transition? Nurses have a pivotal role during care transitions of older patients. More knowledge about their experiences is necessary to develop favorable improvements for this important period in the older patient’s treatment and care. The study has a qualitative explorative design with follow-up focus group interviews. Nurses (N = 30) working in hospital (n = 16) and municipal (n = 14) health care were organized in five mixed focus groups during the period October-January 2014/2015. The focus groups met twice, answering the research questions following a previously circulated semi-structured interview guide. The interview analysis was inspired by content analysis. The analysis resulted in the themes “Administrative demands challenge terms for collaboration” and “Essentials for nursing determine optimal care transitions for older patients”. Administrative demands may prevent nurses’ professional dialogue and collaboration across health care levels. Older patients’ best interests should be ensured through a collaborative relationship between hospital and municipal nurses, to form continuous care across health care levels. Clinical practice should be aware of essentials for nursing, which could influence and facilitate a more individualized and continuous transition for older patients.