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.

Keywords

chronic illnesses discharge coordination elders transitional care nurses

Introduction

The population of older people with multiple chronic conditions is increasing worldwide, and in Denmark more than a third of the population is currently living with two or more chronic conditions.¹ Due to their multiple and diverse contacts with the healthcare system,² care trajectories of older people with multiple chronic conditions are often complicated by risk factors such as social barriers, deficits in activities of daily living (ADL)³ and polypharmacy.^4,5 In transitions between hospital and municipal healthcare settings, older people with chronic illness may experience challenges in managing their healthcare needs,⁶ as well as low quality of life,⁴ and loss of ADL function.^4,5 Consequently, the challenges may lead to acute illness,^5,6 hospital re-admission,^2,4,7 increased primary healthcare consumption,^5,6,8 and increased mortality.^2,6,9

Transitional care denotes the wide variety of time-limited services designed to ensure healthcare continuity and avoid preventable poor outcomes among at-risk populations as they move from one level of care to another, among multiple providers, and across settings.^10,11 More specifically, transitional care often focusses on highly vulnerable older people with chronic conditions, throughout critical transitions in health and healthcare.^10,11 Transitional care nurses (TCNs) were introduced in the US in the 1980s to ensure continuity and process in transitional care of older people with multiple chronic illnesses,¹⁰ and developed through the theory of transition presented by Meleis.¹² Transition was defined by Meleis as the process and results of a passage or a movement from one state, condition, or place to another, in a complex person–environment interaction.¹² Within this definition of transition, a Transitional Care Model was developed by Naylor and colleagues consisting of ten inter-connected components of TCNs’ actions targeting transitions of older adults with multiple chronic conditions: 1) relying on TCNs; 2) managing symptoms and other risks; 3) maintaining relationships with patients and caregivers; 4) engaging patients and caregivers; 5) educating/promoting self-management; 6) screening at-risk older adults; 7) collaborating with patients, caregivers and team; 8) promoting continuity; 9) coordinating care; and 10) delivering services from hospital to home.¹³

Transitional care interventions have internationally been applied with success to complex settings, such as mental healthcare,¹⁴ patients with heart failure,^9,15 cognitive impairment and dementia,¹⁶ chronically ill adults,¹⁴ and discharged elderly inpatients.^7,8 Significant positive effects such as lower patient mortality,^9,15 reduced hospital re-admission rate,¹⁶ lower healthcare and emergency service utilisation,¹¹ decreased length of stay,¹⁶ higher quality of life, and patient satisfaction,⁸ have been found by implementing the transitional care model to practice.

In order to support transitions between hospital and home for older people with multiple chronic illnesses, elements from the transitional care model were introduced in a TCN role at a Danish university hospital in the year 2020. Twenty-eight nurses employed either at the university hospital (n = 17) or in a municipality (n = 11) held the role of TCN, due to their extensive engagement or interest in complex hospital admissions and discharges, as an addition to their employment position. The nurses held different positions, including registered nurses conducting direct patient care and those in administrative functions as discharge coordinators. However, the specific tasks, responsibilities, and function of the TCNs were left undetermined, leaving the TCNs without precise directives regarding how to reduce adverse events and re-admissions during transitions and discharges.

In order to further develop the role and function of TCNs, knowledge is needed on the practices and specific tasks and responsibilities of TCNs to support transitional trajectories for older people with multiple chronic conditions. The aim of this study was therefore to explore and describe TCNs’ practices related to transitional trajectories of older patients with multiple chronic conditions and to gain insight into their experiences of their role and tasks and how their role could be strengthened.

Methods

Design

A qualitative design was used to explore the study aim. Data were collected through focused participant observations and group interviews and analysed using a thematic analysis developed by Braun and Clarke.¹⁷ The study was conducted in accordance with the Consolidated criteria for reporting qualitative studies (COREQ) 32-item checklist.¹⁸

Setting and participants

The study was conducted in a Danish university hospital and six municipalities. The university hospital comprises 300 beds with a mix of generalised and specialised care. The 28 TCNs were approached during a TCN-network meeting, led by the last author, where the study purpose and level of participation was presented. The TCN-network meetings are conducted monthly by the last author to strengthen relationships among TCNs and improve collaboration across settings. Thereafter, all 28 TCNs were invited by email to participate in focused participant observations and/or group interviews. As described, the TCNs’ functions and tasks were not well established: several of the invited participants replied to the emailed participation invitation with queries about the relevance of their participation due to their limited length of experience as TCNs. However, they were assured that their participation would be meaningful since the aim was to investigate and describe their practices to gain a broader understanding of TCNs and how the role could be further developed. In total, 12 TCNs accepted the invitation to participate in the focused participant observations (n = 11) and/or in the group interviews (n = 5). Four TCNs participated in both. The participants were all women, with a mean age of 41 years (range 31–55 years), and an average of nine years’ experience as a registered nurse. The TCNs employed as clinical nurses in direct patient care had experience ranging from one to three years, whereas the TCNs employed as discharge coordinators had nursing experience ranging from 13 to 29 years. All participants had practice experience in both hospital and municipality care settings.

Data collection

Data were collected through focused participant observations and group interviews with the TCNs from January to February 2021. This was done to create a diversity in data, by combining ‘what is seen’ with ‘what is heard’.¹⁹

Focused participant observations

To explore and describe the TCNs’ practices related to the transitions of older patients with multiple chronic conditions, focused participant observations were performed according to Spradley’s methodology.¹⁹ Focused participant observation sessions were conducted by the first and last author among 11 TCNs employed at the hospital and three employed in a municipal setting. The focused participant observations were conducted in four-hour sessions, focusing on specific actions related to transitions for older patients with multiple chronic conditions. An observation guide was created, focusing on the ten inter-connected components of TCNs’ actions targeting transitions described by Naylor and colleagues.¹³ Field notes were written during and after the observation sessions (Table 1).

Table 1.

Focused observation areas based on Naylor and colleagues’ ten components of transitional care.¹³

Components of transitional care	Definition	Focus areas during observations
Relying on the TCN	TCNs assume primary responsibility for transitional care services focused on management of patients throughout episodes of acute illness.	Identification of patients and situations How do the TCNs identify at-risk patients? How do the TCNs get in contact with the patient? How do the TCNs handle the complexities in the patient’s situation? How do the TCNs identify and handle patient risk factors? How do the TCNs handle the responsibility of the patient’s trajectory?
Managing symptoms and other risks	Identify and address patients’ priority risk factors and symptoms.
Screening at-risk older adults	Transitional care service: a standardised protocol to target hospitalised older adults who are at risk for poor outcomes.
Maintaining relationships with patients and caregivers	Establish and maintain a trusting relationship with the patient and family caregivers involved in the patientss care.	Involvement of patient and relatives How do the TCNs involve patients in planning and execution of care, in the discharge process, and in handling worsening symptoms? Do the TCNs educate and inform the patient about care, discharge or relevant initiatives? Do the TCNs use written material when educating and informing the patient? At what point does the collaboration and communication between the TCN and the patient take place? How do the TCNs collaborate and communicate with the patients’ relatives? How do the TCNs involve relatives in planning and execution of care, in the discharge process, and in handling worsening symptoms?
Engaging patients and caregivers	Engage older adults in design and implementation of the plan of care aligned with their preferences, values and goals.
Educating/promoting self-management	Prepare older adults and family caregivers to identify and respond quickly to worsening symptoms.
Collaborating with patients, caregivers, and team	Promote consensus on plan of care between older adults, family caregivers, and members of the care team.
Promoting continuity	Transitional care services are designed to prevent breakdowns in care from hospital to home by keeping the same clinician involved across these sites, using evidence-based strategies to communicate patients’ priority needs, goals and plans of care.	Organisational collaborative areas How do the TCNs inform and involve colleagues about the patient’s situation? Do the TCNs allocate assignments to colleagues, and if so, who? How can the TCNs’ area of responsibility be observed? How do the TCNs secure coordination and communication of the patient’s trajectory between hospital and municipality? Do the TCNs recognise the patients’ difficulties? How many contacts do the TCNs have during the day? How do the TCNs document their work?
Coordinating care	Promote communication and connections between healthcare and community-based practitioners.
Delivering services from hospital to home	Transitional care programmes begin during a hospital admission, with visits occurring in the hospital and at home following hospital discharge.

Notes. TCN: transitional care nurse.

Group interviews

Two group interviews were conducted at the university hospital to explore and describe the TCNs’ experiences of their role and tasks, and how the TCN role could be further strengthened. Group interviews were chosen for data collection instead of individual interviews in order to merge the viewpoints of participating TCNs from both hospital and municipal settings.²⁰ Five TCNs accepted the invitation to participate in the group interviews. Lack of time and transportation issues were the most frequently voiced reasons for declining the invitation. Two group interviews were conducted on two different dates due to the participants’ work schedules. In the first group interview, two TCNs from the municipality participated, with the first and last author as moderator and interviewer, respectively, and in the second, one TCN from the municipality and two from the hospital participated, with the last author as interviewer. An interview guide inspired by Kohlbry and colleagues²¹ and the focused participant observations was developed in order to investigate the role, experiences and expectations of TCNs. The interview guide consisted of four overall questions, as seen in Box 1.

Box 1.

Interview guide for group interviews.

What is the first thing that comes to mind when I say transitional care nurse?

How would you describe your role and responsibility as a transitional care nurse?

˚ Are there specific knowledge, experience, and competencies the transitional care nurse must have?

How would you describe the components of a complex transitional trajectory?

˚ How do you identify patients who have complex trajectories?

How would you describe the ideal transitional care nurse?

˚ What should the role ideally consist of, regarding tasks and functions?

˚ Should the transitional care nurse be employed in specific positions?

˚ What nursing experiences should be required for a transitional care nurse?

The two group interviews were recorded digitally and lasted 1 hour and 40 minutes and 1 hour and 17 minutes, respectively. The conversations were transcribed verbatim by the last author.

Data analysis

Data from the focused participant observations and the group interviews were analysed using thematic analysis as described by Braun and Clarke.¹⁷ Thematic analysis is an approach for conducting qualitative analysis which consists of six phases: the first three phases focus on familiarisation with the data through reading the transcripts, generating initial codes, and searching for themes, and these phases were conducted individually by the four authors. Collectively, more than 60 initial codes were identified and sorted into broader themes individually by each author. The three final phases of analysis were conducted through group discussion between the four authors. The themes were jointly reviewed and an overlap of initial codes were identified concerning the differences in TCNs’ practice as well as similarities in the focus of the TCN role.

Ethical considerations

All participants received written information concerning the study essentials, author credentials, judicial rights, and amount of participation when they were invited to the study. The participants also received this information verbally on the days of data collection and completed a written consent form. The study was approved by the Danish Data Protection Agency (REG-146-2020).

Even though the last author was the leader of the monthly TCN-network meetings, an effort to prevent participants from feeling coerced to participate was made prior to the data collection.

Findings

The interpretation of data from the focused participant observations and group interviews revealed the overarching theme of ‘Building bridges from different settings to a common ground’, which described how TCNs worked to strengthen communication and collaboration between the hospital and municipality settings when planning transitions, but also within their respective organisational settings. The overarching theme was fractured into and supported by three themes of ‘Practice depends on the setting’, ‘Building external and internal bridges’, and ‘Towards a common ground’, which further explained the TCNs’ different practices in the two settings and how they shared a common goal for their role and the transitions regardless of their employment position. The findings are presented as the three themes and elaborated through related sub-themes (Figure 1).

Figure 1.

Overarching theme and sub-themes of transitional care nurses’ practice.

Practice depends on the setting

This theme reflected the fact that the TCNs were employed in different positions and settings in hospital or municipality care. Although there were some similarities in practices across settings, TCNs in different settings had different responsibilities and work areas, leading to very different versions of the TCN role. The theme is elaborated through the sub-themes of ‘Employment settings determine daily practice’ and ‘Securing transitional trajectories as a common goal’.

Employment settings determine daily practice

Depending on their role and work setting, either in the hospital or the municipality, TCNs worked in different ways to support the transitional trajectories of older patients with multiple chronic conditions. TCNs employed in the hospital identified older patients with complex transitional trajectories and collaborated directly with them in terms of planning discharge and home care, as well as contacting healthcare professionals in the municipalities and relatives. Municipality TCNs were mostly employed in administrative positions coordinating care initiatives for the discharged patients. They were not responsible for identifying patients with complex trajectories and had no direct contact with the patients. Rather, their responsibility was to coordinate and allocate care to healthcare teams.

The role and tasks of the TCNs in coordinating the complex transitions of older patients with multiple chronic conditions differed depending on their role as either discharge coordinators or clinical nurses conducting direct patient care. Discharge coordinators employed at the hospital or in the municipalities were responsible for organising transitional trajectories between the hospital and home before practicing as TCNs, and continued to have this focus. Typically, these TCNs needed to have an overview of the department’s capacity in order to plan and execute discharges. TCNs occupied with direct patient care in either setting typically focused on the transitions of a few specific patients and did not focus on overall capacity in the way the discharge coordinators did. In the field notes from the focused participant observations of a TCN working as a clinical nurse, it was noted that:

[The nurse] is occupied with direct patient care and the planning and execution of discharges of her own patients. The department goes by the norm that all nurses should be able to manage discharges.

Likewise, clinical nurses practicing as TCNs in the municipality setting were never involved in coordinating the discharge of patients. This meant that their function as TCNs was determined by both the employment setting and the individual’s role as either discharge coordinator or clinical nurse.

Securing transitional trajectories as a common goal

Even though the TCNs were employed in different roles and settings, they all seemed to strive for a common goal with regard to older patients with multiple chronic conditions: coherent transitional trajectories. Across settings, they described their main goal of ensuring older patients’ transitions was designed to avoid adverse events, worsening of the patient’s condition, and re-admissions. One of the TCNs described it from her perspective:

The coherence of the transitions is the most important thing. It’s all about seeing the complex picture – because the picture is different depending on which setting you see it from [hospital or municipality] (…). Because one thing is what you try to initiate for the patient from the hospital, but it has to be communicated well to the municipality care setting. (Participant C, group interview 2)

Communication between TCNs in the hospital and in the municipality was extremely important for their collaborative abilities in terms of securing the best and safest transition for patients.

Building external and internal bridges

In the theme ‘Building external and internal bridges’, the informants’ experiences were interpreted to highlight two different collaborative roles. The TCNs described that their focus was on the transition between hospital and home – an external collaboration. However, the TCNs’ tasks were equally focused on internal coordination, as they cooperated with other nurses and health professionals within their organisations to coordinate transitions for their older patients. The theme is elaborated through the sub-themes of ‘External collaboration’ and ‘Internal coordination’.

External collaboration

The collaboration between hospital and municipality was described by the TCNs as the most important focus concerning the complex transitional trajectories. The collaboration between the two health sectors was described by the TCNs as complicated and difficult due to prejudices from both sides related to perceptions of a lack of competency and engagement of the other. This was also related to problematic communication through the available IT systems of the hospital and the municipalities. However, the TCNs described that the newly established TCN-network enabled them to get to know each other across settings, and talk about the difficulties they experienced with transitional care and how to collaborate to solve the complexities. One of the group interview participants stated:

It really makes a difference that we know each other and what we each bring to the table – this creates a mutual respect related to what the other part delivers. We have often seen a demonstration of power between hospital and municipality and problems with communication, where one part always thinks the other one is doing a terrible job. (Participant D, group interview 2)

The TCNs from the hospital and municipalities met once a month in the TCN-network which provided them with knowledge of the opposite setting and their individual problems. The TCN-network was considered by the TCNs as a platform for creating collaborative relationships and cultivating respect for each other’s work.

Internal coordination

Within the hospital settings, TCNs coordinated discharge care with nurses, physicians, and physiotherapists at the wards; work that was described as internal coordination. This coordination assisted TCNs in determining when older patients were ready for discharge and the level of care and support needed after discharge. Knowledge transfer between TCNs and other nurses and healthcare professionals in their own setting was considered important for the TCNs in the coordination and planning of transitional trajectories of older patients with multiple chronic conditions. One of the group interview participants considered the point:

The complex discharges are also made complex because of all the different perspectives needed from other healthcare professionals to ensure a safe transfer to the patient’s home. (Participant E, group interview 2)

In the municipalities, the TCNs in administrative positions were not in direct contact with patients and therefore relied on home care staff to provide information about the specific needs of older patients. Often, the home care staff were social workers and healthcare workers who had not received education or training in managing complex health conditions such as multiple chronic conditions. TCNs in the municipalities were concerned about the home care staff’s ability to adequately assess and understand the complexity of the condition of the older patients in their private homes and therefore were uncomfortable leaving such a responsibility to the staff in question. As a participant in one of the group interviews noted:

I need to know what I have handed over to the home care staff and I have to be sure that they can manage the task. (Participant B, group interview 1)

TCNs were concerned about whether the home care staff were sufficiently capable to manage the complex task of caring for newly discharged patients at home, and whether they would know when to ask for help if the situation became too complex. Essentially, this concern was related to the TCNs’ main goal of planning and executing safe transitional trajectories from hospital to home.

Towards a common ground

The interpretation of data revealed common understandings among the TCNs about how their role could be further strengthened, which is elaborated through the sub-themes of ‘Common prerequisites and competencies’, ‘Being different but similar’ and ‘Strengthening communication’.

Common prerequisites and competencies

The TCNs emphasised the importance of having several years of work experience in order to fulfil the role of a TCN. They stated that a newly educated nurse would not have a sufficient understanding of the many different simultaneous tasks a TCN performs. Furthermore, the TCNs described that a candidate for the TCN role should ideally possess work experience in both hospital and municipality care settings:

I still claim that you shouldn’t become a TCN if you don’t have work experience from both hospital and municipality care (…). You can’t build bridges if you don’t know what you are building bridges to. (Participant A, group interview 1)

According to the participants, it was important that TCNs possess work-related knowledge about both settings to be able establish a connection between them and to understand the differences in culture and practices.

Being different but similar

The participating TCNs explained that it was ideal for their role and function as a TCN to be different, according to the tasks that are relevant in either the hospital or the municipality setting. However, all TCNs should have the same focus and strive for common goals. Discharge coordinators at the hospital and in the municipalities were described as aligned with the goal and focus of the TCN role. The participants emphasised the specialist and administrative nature of their role due to the multi-faceted tasks required to ensure and support the transitional trajectories of older patients with multiple chronic conditions. They stated that a clinical nurse occupied with traditional patient care would not have enough time allocated to thoroughly complete the many tasks of complex transitions. The TCNs agreed that it would be ideal to have discharge coordinators with TCN responsibilities employed in every hospital department and every municipality. They built this claim based on previous criticism from municipality nurses who had experienced insufficient planning of discharges from departments without such discharge coordinators.

We need a clarification of what type of nurse you want to be a TCN. If it’s a home care nurse, then how can she build a bridge when she is not in contact with the hospital regarding discharges? It has to be a similar function in both hospital and municipality settings, so we need discharge coordinators in both settings, because they have the connection to each other. (Participant A, group interview 1)

The TCNs also emphasised that, ideally, all municipalities should work in care teams with availability 24 hours a day, seven days a week, consisting of both nurses and home care staff, to ensure safe discharge and identification of fragile older patients’ needs.

Strengthening communication

In order to work towards common ground for the TCN role, the TCNs stated that knowledge of each other’s work was important to strengthen their collaboration and communication. They proposed an internship in the municipality for hospital TCNs, and vice versa, to allow each group to understand the different tasks of the role. The TCNs also stated that communication between the hospital and municipalities needed to be improved due to IT-related communication issues. They also expressed a need for a discharge process that was more dialogue-based, though it was already improving due to relationships via the TCN-network. Additionally, the TCNs explained that it was important to re-establish discharge meetings when particularly fragile older patients were discharged from hospital to home. As one TCN explained:

We have cut down on many meetings – among other things, the plan meetings when the patient is coming home either from the hospital or from rehabilitation. So, you don’t get to discuss the terms and expectations between sectors, patients, and relatives. Right now, the information has to go through many links and many contacts, and this is where it can go wrong. (Participant B, group interview 1)

The TCNs explained that face-to-face meetings provided a solid ground for collaboration and facilitated communication and a thorough review of plans both with and for older patients with multiple chronic conditions.

Discussion

Our aim was to explore and describe TCNs’ practices related to transitional trajectories of older patients with multiple chronic conditions and to gain insight into their experiences of their role and tasks and how their role could be strengthened. TCNs’ experiences of their role and tasks were reflected by the overarching theme of ‘Building bridges from different settings to a common ground’. Building bridges described the TCNs’ endeavour in strengthening their collaboration across the settings of hospital and municipality care. In order to collaborate across the healthcare sectors they needed to find a common ground, in the middle of the bridge, where coordination of the complex transitions for the older people with multiple chronic conditions could succeed.

Building bridges from different settings in an external collaboration was the initial focus of the TCNs, and depended on their efforts and interests in collaboration as well as their different employment positions and settings. The TCNs were positioned in both the hospital and municipalities, which they deemed necessary and important in order to plan and ensure safe transitions for older patients with multiple chronic conditions between hospital and home. They reported that collaboration and coordination of health and care initiatives between the hospital and municipality faced well-known complications due to the different policies and organisation of the two healthcare settings. In order to build bridges of collaboration and communication, the TCNs are required to speak the same language regarding patientcare and treatment. However, due to the different organisational environments in the hospital and in municipality care, the difference between being a specialist at a hospital department and a generalist in municipality care can be too large. This finding is consistent with studies showing that negative presumptions about another group’s work can complicate collaboration and communication between settings.^22–25 A qualitative study on hospital and home care registered nurses’ experiences of cross-sectoral collaboration related to the transitional care of frail older patients revealed that nurses experienced the hospital and municipality home care as ‘two worlds’.²⁶ That study also showed that communication among nurses was insufficient to establish collaboration related to transitional care due to the different cultures and professional identities in the two settings and divergent IT systems.²⁶ The TCNs in our study expressed that collaboration between hospital and municipalities was strengthened through their inter-relations within the regional TCN-network. The network meetings provided a forum for TCNs to discuss difficulties in transitional care, and to gain mutual understanding and respect for each other’s settings, cultures and ways of working. Petersen and colleagues²⁴ found that direct meetings and conversations between nurses in hospitals and municipality care improve collaboration for planning transitional care. Lemetti and colleagues²⁷ describe that meeting in a respectful way is pivotal for effective collaborations.

The TCNs also described how building bridges was related to an internal coordination, consisting of collaboration and coordination within their respective organisational settings. The TCNs considered the internal coordination to be a team effort, where complex discharge care planning for older patients with multiple chronic conditions depended on clinical input from clinical nurses, physicians and physiotherapists. This fits the recommendations of the Transitional Care Model, which focuses on the importance of inter-professional collaboration, promoting consensus on plans of care between older adults and members of the care team.¹³ The significance of inter-professional collaboration in discharge planning has been investigated in the literature mainly in regard to improvements in cost savings, patient safety and satisfaction at discharge,²⁸ unplanned re-admissions,²⁹ and adverse events.³⁰ Furthermore, standardised communication between inter-professional healthcare professionals and structured team interactions has proved to increase patient safety outcomes.³⁰ The majority of TCNs from the municipality care settings were employed in administrative functions as discharge coordinators, which meant they had sparse contact with other healthcare professionals in their organisation in coordinating discharges. Their job was to focus on the external collaboration with the hospital in coordinating care at home for the older patients after discharge. However, a strong focus should further be on a full team collaboration in the municipalities, where general practitioners, physiotherapists and home care registered nurses are involved in planning care for the patients.

In order to reach common ground in bridging their collaboration, the TCNs in our study stressed how their role should be further strengthened. It was paramount for the TCNs that their role became an all administrative specialist function, in both the hospital and the municipality, to provide the role with focus on and time solely for complex transitions. The TCNs employed as discharge coordinators in the hospital and municipalities expressed concerns about clinical nurses being TCNs due to their lack of time to comprehensively plan and coordinate the complex transitions for all patients in their department. This aspect was also discussed in a learning intervention study of nurses’ transformative agency in transitional care for older adults,³¹ in which 16 nurses from hospital and municipal settings expressed concerns about how complex discharges had become, and how the department had to use resources for discharge coordinators to secure the discharges. One could argue that all nurses are educated to handle complex discharges of older patients. Even though that is true, not all registered nurses working with direct patient care in hospital or municipality care settings have the time for the long and complex process of a successful discharge with multiple care coordination. The TCNs in our study stressed that uniformity in the role was paramount, and that they experienced a decrease in the quality of discharges when clinical nurses were in charge. Discharges of patients with complex care needs were often time-consuming and, due to a lack of resources, clinical nurses were not able to dedicate sufficient time for a comprehensive discharge plan for all patients in their departments. Uniformity in the TCN role could be seen as supporting Naylor and colleagues’ transitional care model of ten interconnected components,¹³ mentioned in the background section. A cross-sectional survey of the work areas of 28 TCNs showed that self-reported confidence was highest in promoting communication and connections between healthcare and community-based practitioners (fostering coordination), preventing breakdowns in care from hospital to home by having the same clinician involved across these sites (promoting continuity), and targeting adults transitioning from hospital to home who are at high risk for poor outcomes (screening).³² The cross-sectional survey, however, revealed a difference between the work areas of TCNs employed at hospitals, who reported higher mean score of agreement with the work area statements, and TCNs in municipal settings.³² This could be related to how the differences within the TCNs’ practices of coordination and planning of transitional trajectories depend on their employment setting.

Methodological considerations

The present study was based on data generated through focused participant observations and group interviews. In this type of research, triangulation of methods, data sources and researcher perspectives serves as a way to establish trustworthiness and to validate the interpretations made. In this study, the combination of focused participant observations and group interviews also provided an opportunity to reach diversity in data by combining ‘what is seen’ with ‘what is heard’.¹⁹

In this study, two group interviews were performed to explore and describe the TCNs’ practices related to the transitions of older patients with multiple chronic conditions. Group interviews were conducted instead of single interviews, to create a discussion of the TCNs’ viewpoints. Even though only two and four TCNs, respectively, participated in the two group interviews, which could be described as mini-groups,³³ the TCNs participated on a high level in sharing their opinions and experiences.

This study was conducted in relation to TCNs in one region of Denmark. The findings relate to this particular setting. However, contextualising the presentation of findings may provide sufficient knowledge for others to generalise these findings to other settings.

Conclusions

Building bridges from different settings to a common ground was revealed as the overarching theme based on the authors’ interpretation of data from focused participant observations and group interviews with 12 TCNs. Building bridges was considered the cornerstone of the TCNs’ efforts in strengthening the complex transitions of older patients with multiple chronic conditions, through external collaboration between the hospital and municipality care. The TCNs described their role as pertinent to their mutual goal of securing the discharge process and coordination of care, based on being employed in both healthcare sectors in similar positions as discharge coordinators and with practice experience from the hospital and municipality care. By building bridges across the healthcare sectors, the TCNs could strengthen their focus on the elements of the complex transitions for the sake of the patients’ well-being. Additionally, the regional TCN-network was viewed as essential for the TCNs in order to continue to strengthen relationships between the TCNs, generating both respect and understanding of each other’s work, cultures, and organisational settings. The authors findings led to the conclusion that strengthened collaboration between TCNs depended not only on external collaboration across hospital and municipality settings, but also on internal coordination, as complex discharge care planning for older patients rests on inter-professional teamwork.

Our findings provide knowledge for clinical practice to support the improvement of transitional trajectories for older patients with multiple chronic conditions. The external collaboration of specialised nurses focusing on the discharge process could have implications for older patients with multiple chronic conditions, due to the enhanced coordination of care from the hospital to the municipality care. When complex discharges are handled by TCNs in specialised positions, time is released for the registered nurses working with direct patient care, as they avoid spending time on multiple contacts with the municipality settings. However, further research is needed on older patients’ needs and experiences during transitions between hospital and home to support evidence-based practice, a framework that considers patients’ preferences to be as substantial as systematic research and clinical experience.³⁴ Future research will also explore the recommendations identified by the TCNs in this study, in an effort to develop and implement a transparent model for the role and practice of TCNs’ external and internal collaborations.

Footnotes

Acknowledgements

We would like to thank the transitional care nurses for their time and effort in participating in our survey.

Author contributions

Study design: CB; Data collection: NM and CB; Data analysis: NM, MGK, BL and CB; Manuscript preparation: NM, MGK, BL and CB; Critical review of the manuscript: NM, MGK, BL and CB. All authors approved the final manuscript.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. However, the research study was financially supported by Zealand University Hospital and Aalborg University Hospital, Denmark.

ORCID iDs

Mette Geil Kollerup

Connie Berthelsen

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