Abstract
Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains. In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be 'ready to be discharged'. We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.
Highlights
Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes
Challenges: In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning
We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future
Summary
Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Challenges: In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses’ different perspectives influence their assessment of patients’ need for post-hospital care, and how nurses have different understanding of what it means to be ‘ready to be discharged’. The quality of the interaction between hospital and community health care systems must improve if the health care system is to meet future demands related to an increased number of elderly and chronically ill people [1, 2]. Deficits in communication and information transfer and lack of coordination when patients are
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