Commentary on: The lived experience of the stroke survivor-caregiver dyads during the transitional care from hospital to home with teletraining and telesupport educational program: a phenomenological study.

The transition from hospital to home is a critical phase for stroke survivors and their caregivers, often marked by complex and unmet needs due to fragmented care. Understanding how dyads experience this phase is essential to ensure continuity and quality of post-stroke care. Although various educational programmes have been studied, few have examined the lived experiences of dyads participating in an integrated teletraining and telesupport programme during transitional care. This qualitative study explores these experiences in the first month after discharge to inform improvements in transitional care and the development of tailored telehealth programmes. A phenomenological study was conducted using Cohen's methodology. Dyads received predischarge training through videos and nursing support. Open-ended interviews were conducted between October 2023 and June 2024. Data triangulation enhanced analytical rigour. Fourteen dyads were enrolled (mean age 62 years; 46% men, 54% women), including spouses, cohabiting partners, siblings, and adult children. Two overarching themes emerged: Transitional Care Impact on Dyads (three subthemes) and Meeting the Holistic Needs of the Dyad (five subthemes). Findings suggest that teletraining and telesupport programmes may support post-stroke transitional care, fostering dyadic well-being and reducing anxiety and isolation. Given the qualitative design and small sample size, transferability is limited. Further research across diverse settings is needed to validate and extend these insights.

Review question/objective The aim of this systematic review is to describe the process of inter-shift nursing handoff procedures and to identify commonly used strategies and techniques associated with the handoff. Specifically, in relation to inter-shift nursing handoffs in acute care settings: • How were they conducted? • Where were they conducted? • How was information transferred? • What purpose(s) did the handoff serve? • Can best practice related to knowledge transfer during transitions in care be identified? Inclusion criteria Types of participants The review will consider studies that include nurses engaged in handoff activities in adult acute care settings at the time of inter-shift nursing report. Types of intervention(s)/phenomena of interest This component of the review will consider the following phenomena of interest: The processes associated with inte-rshift report on acute care nursing units, specifically, where they were conducted, how information was transferred between or among participants, and what information was transferred between or among participants. Types of outcomes Outcomes of interest are connected to the process of inter-shift nursing handoffs in acute care settings. Outcomes are related to the various purposes the handoff may serve, in addition to the transfer of patient care information, and the identification of best practice related to knowledge transfer during transition in care.

Objective To investigate the status of transitional care of chronic diseases developed by secondary and tertiary hospitals cooperated with communities in China. Methods Self-designed questionnaires were used to investigate the status of transitional care of chronic diseases developed by 109 secondary and tertiary hospitals of 30 provinces in China. Results About 94.5% thought that it is vital to carry out transitional care of chronic diseases; 88.1% considered that it is necessary to realize the linkage and interaction of transitional care of chronic diseases between hospitals and communities; whereas only 51.4% expressed their intention to participate in this project. 88 hospitals (80.7%) said the status of transitional care of chronic diseases was not well; 61 hospitals thought that the content of transitional care was not standardized; 68.9% considered that their leaders do not care about and support transitional care; 85 hospitals (78.0%) said that there is no enough human resources to carry out transitional care. Transitional care was carried out well in following four aspects in secondary and tertiary hospitals, namely, health education before discharge (82.6%) , discharge planning (80.7%) , specialist out-patient of chronic diseases (72.5%) , and regular follow-up after discharge (72.5%) . 106 hospitals (94.5%) had a cooperation with continuities in transitional care of chronic diseases. As for the content, transitional care was carried out well in three aspects: 76 hospitals (69.7%) set up two-way referral center, 62 hospitals (56.9%) provided professional guidance, technical assistance and accept community people to study, besides, 59 hospitals (54.1%) cooperated with communities to help patients make an appointment of outpatient and examine. Forms mainly included research project (82.6%) and health lecture (77.1%) , etc. Conclusions Transitional care of chronic diseases has been carried out in most secondary and tertiary hospitals in our country, in spite of the general condition, there are still some block factors, transitional care programs should be improved and managed further to provide and strengthen the linkage of hospitals and communities, so as to forming a standard system reference for effectively construct a three-dimension linkage (Hospital-Community-Family) mode of transitional care. Key words: Chronic diseases; Hospital; Community health center; Transitional care; Status investigation

IntroductionTransition of care for a patient between hospital and home can cause disruption to normal routines, increasing the risk of medicines-related harm. The transition from hospital to home is more...

Objective To investigate the effect of transitional care on postpartum negative mood for puerpera. Methods One hundred sixty eligible puerperas were recruited between January 2013 and October 2014. By order of hospitalization, participants were randomly assigned into two groups. The control group (80 cases) received routine care. The study group received transitional care which consisted of predischarge assessment, structured home visits and telephone follow-ups, psychological rehabilitation group activities, phone and internet consulting services within six months after discharge. Screenings of predischarge depression and anxiety symptoms of the study group were done by Hospital Anxiety and Depression Scale (HADS). Evaluations of depression and anxiety symptoms of two groups were done by Edinburgh postnatal depression scale (EPDS) and Self-Rating Anxiety Scale (SAS)on postpartum forty-two days and six months. Results There were no differences in demographics, maternal indicators and completion of follow-up between groups (P > 0.05). On postpartum forty-two days, the study group had significantly better depression and anxiety scores (P 0.05). On postpartum six months, the study group had significantly better depression and anxiety scores, less incidences of depression and anxiety than the control group (P < 0.05). The depression and anxiety scores of the study group were 7.13±2.52 and 42.6±6.0, those of control group were 8.87±2.66 and 48.8±5.9. The incidences of depression and anxiety of study group were 6.4% (5/78) and 7.7%(6/78), those of control group were both 26.0% (20/77). Analysis of multiple linear regression suggested that age, education level and family income would affect transitional care intervention on postpartum depression. Conclusions This study established a nurse-led transitional care model which selected the gynecology and obstetrics professional nurse as advanced practice nurse. Results demonstrated that transitional care was effective on improving maternal postpartum depression and anxiety. Key words: Depression; Anxiety; Transitional care; Postpartum

Long-term survival in childhood cancer is excellent. Most survivors will have a therapy-related chronic condition, yet very few receive survivor-focused care as they transition from adolescence to young adulthood. The purpose of this study is to identify indicators of success in current transitional care practices for young adult survivors of childhood cancer as defined by all members of survivorship care teams. An exploratory, phenomenologic qualitative study was conducted with key informants from medical teams involved in transitional care of childhood cancer survivors. Data were collected through phone interviews with providers from both pediatric and adult care settings. A multidisciplinary study sample of 29 participants from three institutions identified two major themes with multiple subthemes. The first major theme was that providers must be good communicators, and it emphasized the importance of having good relationships throughout the transition of care to optimize effective communication. The second major theme was that models of care must include well-established partners throughout the healthcare system that promote accessible subspecialty care with streamlined referrals and patient navigation services. From the perspective of experienced pediatric- and adult-centered providers at three different institutions delivering life-long transitional care for childhood cancer survivors, the optimal model of care must be built around facilitating communication among all key stakeholders and emphasizing patient-friendly services that minimize patient stressors.

Living the transition: Experiences of patients receiving palliative care from hospital to home - A phenomenological study.

Adolescence: Challenges and Responses

With changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements related to transitions in care effective July 1, 2011, sponsoring institutions and training programs must develop a common structure for transitions in care as well as comprehensive curricula to teach and evaluate patient handoffs. In response to these changes, within the Duke University Health System, the resident-led Graduate Medical Education Patient Safety and Quality Council performed a focused review of the handoffs literature and developed a plan for comprehensive handoff education and evaluation for residents and fellows at Duke. The authors present the results of their focused review, concentrating on the three areas of new ACGME expectations--structure, education, and evaluation--and describe how their findings informed the broader initiative to comprehensively address transitions in care managed by residents and fellows. The process of developing both institution-level and program-level initiatives is reviewed, including the development of an interdisciplinary minimal data set for handoff core content, training and education programs, and an evaluation strategy. The authors believe the final plan fully addresses both Duke's internal goals and the revised ACGME Common Program Requirements and may serve as a model for other institutions to comprehensively address transitions in care and to incorporate resident and fellow leadership into a broad, health-system-level quality improvement initiative.

Elderly patients, due to their complex medical conditions and extensive care needs, are at risk of experiencing low-quality or fragmented care during transitions between different healthcare settings. After transitioning from hospital to home, inadequate self-care abilities may result in further health deterioration and increased risks of adverse outcomes. Currently, China lacks effective transitional support services from hospital to home, hindering the smooth transition for elderly patients. Therefore, understanding the specific care needs of elderly patients during this period provides a scientific basis for establishing reasonable transitional support services. This study aims to explore the transitional care needs of elderly patients during the hospital-to-home transition, as perceived by key stakeholders-patients, caregivers, and nurses-using Shanxi Province as a case example. A descriptive phenomenological method was employed in this study. Purposeful sampling selected 10 elderly patients, 5 caregivers, and 5 nursing staff from a tertiary hospital in Shanxi Province, China, for semi-structured in-depth interviews. The Colaizzi's analysis was used in data analysis. The transitional care needs of elderly patients from hospital to home can be summarized into four themes: the need to enhance self-care abilities, the need for professional guidance, the need for social and psychological support, and the need for healthcare service resources. Elderly patients have diverse care needs during the hospital-to-home transition, which require urgent attention and support. To address these needs, healthcare professionals should conduct comprehensive assessments during the patients' hospitalization, accurately identifying care issues and implementing team-based interventions. By fulfilling these needs, healthcare providers can ensure that elderly patients are well-prepared psychologically, possess sufficient knowledge and self-care skills, and have access to comprehensive support services from hospitals and communities as they transition from professional hospital care to home self-care.

Objective To investigate the demand of transitional care service for ophthalmology ambulatory surgery patients, provide theoretical and practical evidences for perioperative nursing of ambulatory surgeries, and offer feasible nursing care for ambulatory surgery to further enhance the level of nursing service. Methods The questionnaire was self-designed according to the research purpose and method. It included general data, preoperative and postoperative transitional care demand of ophthalmology day surgery which was composed of 39 items. The questionnaire was distributed and recycled by professional. Descriptive analysis and data statistics was performed using the percentage. Results All 200 questionnaires were issued and 198 questionnaries were collected with an effective rate of 99%. The first three requirements of transitional care in patients were the prevention in the demand for health education (86.87%) , the knowledge of the cause of disease and symptoms (83.84%) , and the understanding of the operation (72.72%) . Conclusions Hospital should establish and perfect the transitional care service mode and nursing team for ambulatory surgery patients, and formulate individual transitional care plan based on actual demands of patients and health education. Key words: Ophthalmology; Health services needs and demand; Day surgery; Transitional care

BackgroundThe transition from hospital to home is a critical period for stroke survivors and their caregivers. This study explores the clinical staff’s attitudes and perspectives on transitional care (from hospital to home) for stroke patients in the neurology department.MethodsThis qualitative descriptive phenomenological study involved semi-structured interviews with 15 clinical staff members in the neurology department of a tertiary hospital, conducted either face-to-face or via telephone. Colaizzi’s method was used to analyze the data.ResultsFive major themes emerged: (1) Clinical staff recognize the importance of transitional care for patients’ recovery post-stroke and the value of building strong relationships with stroke patients; (2) There are diverse understandings of the definition of transitional care, doctors generally have a more accurate understanding, while nurses’ understanding of transitional care needs improvement; (3) Staff perceive challenges in implementing transitional care, including a lack of self-directed learning, time constraints, and limited opportunities for continuous learning; (4) There is a consistent need for education, both doctors and nurses expressed a desire for training, but nurses require fair opportunities for ongoing learning; (5) The establishment of advanced (nursing) specialists is recommended, including specific work positions or specialized professionals.ConclusionsClinical staff in the neurology department could recognize the significance of transitional care for stroke patients. However, heavy workloads, inadequate competence, and limited learning opportunities reported by nurses hinder their participation in transitional care. To ensure quality transitional care, nurses, in particular, need equitable access to training in areas such as stroke pathophysiology, rehabilitation, symptom monitoring and evaluation, communication, and educational skills. Guidance from clinical specialists is strongly recommended to enhance the implementation and quality of transitional care.

Background: Care transitions (CTs) across the care continuum (e.g., hospital to primary care/community), especially for those with complex care needs and multimorbidity, is an important focus for improvement. Complex patients in particular tend to be at higher risk for adverse events such as medication errors and rehospitalization due to poor discharge coordination and communication. Primary care plays a significant role in improving coordination and communication to support successful transitions in care. An ongoing study in Alberta, Canada called A DiseAse-Inclusive Pathway for Transitions in Care (ADAPT) focuses on integrating care by collaborating with Primary Care Providers to enhance CTs. Alberta Health Service (AHS) Primary Health Care Integration Network (PHCIN) has been leading the development of the Home to Hospital to Home (H2H2H) Transitions Guideline for several years. A major aspect of this initiative is evaluating how patients experience transitions from hospital to home. There are few validated patient reported experience measures (PREMs) that capture multiple transition points from discharge preparation, to home, to primary care. The objective of this work was to develop a PREM to capture patients experience of care while transitioning across multiple settings, with a focus on integration of care across. Approach: Methods to achieve our objective included a literature review, identification of core domains and questions across clinical settings, and then pre-testing the instrument with content experts and patients/caregivers with lived experience to establish content and face validity. After iterative pre-testing and revisions, we plan to pilot the newly developed PREM in one site prior to broader application. Psychometric testing of the PREM will be done as part of the larger study which will also explore strategies to bolster response rates from patients involved in this study aimed at improving CTs for adult patients with diverse chronic conditions and better integrating their care. Results: The literature review identified 3 potentially relevant PREM instruments. Criteria for inclusion in the review were an adult patient population, and relevance to transitions in care between hospital and primary care settings. Core domains of interest were superimposed onto PREM items, including patient knowledge, self-efficacy, care preference alignment, integration/coordination, and satisfaction throughout CTs. Existing PREMs were limited in capturing the patient experience as they transitioned through different levels of care. Items for the new PREM were developed to ensure representation of core domains of interest for CTs from hospital to home, including integration with primary care in the post-discharge period. The PREM is currently undergoing pre-testing with patient advisors (n = 5) and content experts (n = 5). Once pre-testing and revisions are complete the PREM will be applied in a small pilot, and then in the implementation evaluation of a provincial transitions in care initiative, i.e., the H2H2H Guideline. Implications: Creating an instrument that captures patient experiences as they move between acute and primary care, with a focus on integrating care will be key to gaining understanding and improving CTs. The development of a PREM to evaluate across levels of care will better inform various interest groups on how different system changes impact the patient experience. This approach to a PREM instrument also reinforces the importance of viewing the patient experience in a more integrated manner rather than in components.There are few validated PREMs in Canada, or elsewhere, that capture patient experiences throughout the transition process across the continuum of care from hospital to home. The PREM we are developing would be applicable to applied research and learning health organizations across Canada given the current gap in this area. The PREM will provide robust evidence to assess patient experience metrics to support quality improvement work and enhance integration of care.

BackgroundPatients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings. TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care.MethodsThis multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to September 1, 2020), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC.ResultsThere were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.6 (SD 0.7) treatments, commonly transitioning from surgery to radiotherapy (21.2%). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over the study period. Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average = 70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: (1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, (2) Relational head and neck cancer care which encompasses patient expectations and relationships, and (3) System and individual impact of transitions in care.ConclusionsThis study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.

Transition is the planned and purposeful movement of adolescents with a chronic health condition into adult services. It aims to promote independence and self-management of young patients with regard to their ongoing health and care needs. However, particular challenges (including a reluctance of patients and families to leave the familiar paediatric environment and increased risk of psychological distress during the transitional period) have been identified as young patients move between these services. Consequently, this care practice has been identified as a key area for national improvement. In searching for ways to address these challenges, practitioners, researchers and policy makers have focused upon implementing care interventions that aim to build independence and responsibility amongst young patients. Given that young people who have epilepsy and severe forms of co-morbid learning disabilities [ELD] may not always reach complete independence from their carers, questions remain as to whether the aims of the transitional process are applicable to this population. Therefore, the aim of this thesis is to (re)specify the transition ‘challenge’ by documenting and analysing the institutional practices and lived experiences of ELD through a transitional care service. This study is the first to ethnographically examine the practice of UK transitional care for young people with ELD. Through a multi-sited ethnographic approach, I show that the transitional care between two hospitals in the north of England (and wider ‘social’ domains such as the family home and social care environments), is a highly situated and negotiated practice. Furthermore, narrative and observational methods of data collection with clinicians, care professionals, families and young people with ELD reveal transitional care to be a practice that is bound up with assumptions about what it means to be an adolescent, tensions in cultures of care, expectations regarding rites of passage and normative conceptualisations of the childhood-adulthood dichotomy. Based on these findings, the central argument of this thesis is that, whilst UK adolescent healthcare is a complex and contested care practice that organises and orders patients based on chronological age, it is also a social practice that operates in the context of wider political agendas and social ideals. In situating ELD transition within its institutional context, this study exposes the sociocultural arrangements that shape contemporary understandings and experiences of adolescence and disability. Crucially, it shows how society and culture shape biomedical practices and understandings of the adolescent patient.