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

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.