Student nurses' experiences with a digital educational resource supporting learning in nursing home placements: A qualitative study.

BACKGROUND: Nursing education should improve clinical placements in nursing homes to foster and enhance student nurses' learning experiences. Initiatives for digital educational resource used to teach and supervise students to complement learning are increasingly being adopted and considered important in nursing education. However, little is known about how digital educational resources can facilitate learning in placements. Research on the value of such resources from student nurses' perspective is required. AIM: To explore first-year student nurses' experiences with a digital educational resource developed to support learning in nursing home placements. DESIGN: This study has a qualitative explorative design and is part of a larger research project in which a digital educational resource named DigiQUALinPRAX was developed. SETTINGS: This study was conducted at three publicly funded nursing homes affiliated with one Norwegian university. PARTICIPANTS: Twenty-three first-year student nurses. METHODS: Data was generated through pre- and post-placement group interviews and analysed using reflexive thematic analysis. Standards for Reporting Qualitative Research were applied in this stud. FINDINGS: One overreaching theme and three subthemes related to student nurses' experiences with a digital educational resource were identified. The digital educational resource gave a feeling of being acknowledged as a learner by (1) providing a structure and preparation that made the placement feel less overwhelming, (2) supporting professional reflection and assessment practices, and (3) facilitating collaboration when all stakeholders used the resource actively. CONCLUSIONS: This study indicates that student nurses' learning process in nursing home placements can be supported through digital educational resources customised for this learning arena. The findings indicate that the digital educational resource facilitated pre-placement preparedness, provided structure and flexibility, and enhanced reflection and assessment practices during clinical placement. However, encouraging tripartite usage is essential to exploit the full potential of digital educational resources.

Usefulness of pedagogical design features of a digital educational resource into nursing home placement: a qualitative study of nurse educators' experiences.

BACKGROUND: The rapid advancement of technology-enhanced learning opportunities has resulted in requests of applying improved pedagogical design features of digital educational resources into nursing education. Digital educational resources refers to technology-mediated learning approaches. Efficient integration of digital educational resources into nursing education, and particularly into clinical placement, creates considerable challenges. The successful use of digital educational resources requires thoughtful integration of technological and pedagogical design features. Thus, we have designed and developed a digital educational resource, digiQUALinPRAX, by emphasizing pedagogical design features. The nurse educators' experiences of the usefulness of this digital educational resource is vital for securing improved quality in placement studies. AIM: To obtain an in-depth understanding of the usefulness of the pedagogical design features of a digital educational resource, digiQUALinPRAX, in supporting nurse educators' educational role in nursing home placements in the first year of nursing education. METHODS: An explorative and descriptive qualitative research design was used. Individual semi-structured interviews were conducted with six nurse educators working in first year of a Bachelor's of Nursing programme after using the digital educational resource, digiQUALinPRAX, during an eight-week clinical placement period in nursing homes in April 2022. RESULTS: Two main categories were identified: (1) supporting supervision and assessment of student nurses and (2) supporting interactions and partnerships between stakeholders. CONCLUSION: The pedagogical design features of the digiQUALinPRAX resource provided nurse educators with valuable pedagogical knowledge in terms of supervision and assessment of student nurses, as well as simplified and supported interaction and partnership between stakeholders.

Exploring stakeholders' experiences in co-creation initiatives for clinical nursing education: a qualitative study.

BACKGROUND: Co-creation is an emerging approach in nursing education, wherein academics engage in multi-stakeholder collaborations to generate knowledge, ideate solutions, promote sustainability, and enhance educational quality. However, knowledge on stakeholders' experiences in participation in co-creation initiatives for nursing education is scarce. This study aimed to explore the experiences of student nurses, nurse educators, and e-learning designers in co-creation initiatives to design and develop a digital educational resource for clinical nursing education. METHODS: The study adopted an exploratory qualitative design. Data were collected via three separate semi-structured focus group interviews with student nurses (n = 7), nurse educators (n = 8), and e-learning designers (n = 3) who participated in co-creation workshops. Collected data were then thematically analyzed. RESULTS: Three themes related to the participants' experiences emerged: (1) The co-creation workshops were enjoyable, useful, and instructive; (2) power imbalances influenced the students' engagement; and (3) contextual factors influenced the participants' overall engagement. CONCLUSIONS: This study shows that co-creation through workshops is a novel, enjoyable, and instructive approach that facilitates knowledge exchange. It also highlights the needs and experiences of stakeholders, especially student nurses. However, the use of co-creation in nursing education presents some challenges. Recognizing and managing power differentials are essential for successful co-creation in clinical nursing education, alongside a mindset of collaboration and mutuality. Future research is required to systematize knowledge about the benefits and impacts of the processes and outcomes of co-creation initiatives, including stakeholders' motivation, barriers, and facilitators to participation in co-creation, to improve the quality of clinical nursing education.

Supporting the nurse educator in clinical education - a qualitative evaluation of a digital educational resource DigiVIS.

BACKGROUND: Despite the increased use of technology for teaching and learning in clinical nursing education, relatively little attention seems to be directed toward the usefulness of digital educational resources (DERs) to support nurse educators' educational role in clinical nursing education. METHODS: An interpretive descriptive qualitative study design was conducted to evaluate the usefulness of a DER to support nurse educators in clinical nursing education. Data were collected through two focus group interviews with part-time and novice educators (n = 5) and full-time, more experienced educators (n = 5), after they had overseen student nurses in nursing home placements. Data were analyzed using thematic analysis and Standards for Reporting Qualitative Research guidelines were used for this study. FINDINGS: The analysis identified three themes related to nurse educators' experiences of the usefulness of a DER to support their educational role while overseeing first-year students on clinical placements in nursing homes: (1) Provides academic support and a sense of security (2) promotes pedagogical efficacy, and (3) represents a flexible resource for educational planning. CONCLUSION: This study shows that a digital educational resource can be an efficient and useful supplementary strategy to support the nurse educator's role in clinical nursing education. Future research is required to systematize knowledge about the impact of DERs on orientation and training, as well as motivation and facilitators for, and barriers to, their use to enhance quality and strengthen the nurse educator's role in clinical nursing education.

A digital educational resource to support and enhance effective mentorship practices of nursing students in nursing homes: a qualitative study.

BACKGROUND: There is a grooving body of evidence emphasising the need to support and enhance effective mentorship practices for nursing students in nursing home placements, including strengthening of the pedagogical competence of registered nurse mentors. Owing to the necessity for multifaceted mentoring competence and the challenges of workload registered nurses are facing, the use of flexible digital educational resources has been suggested. However, current knowledge on the effectiveness of digital educational resources in enhancing mentorship practices in nursing homes is scarce. This study aimed to explore the perception of registered nurse mentors regarding the effectiveness of a digital educational resource, particular its usability and value-in-use in supporting and enhancing mentorship practices in nursing homes. METHODS: The study applied an exploratory descriptive qualitative design. Pre- and post-mentoring semi-structured focus group interviews were conducted among a total of 23 registered nurse mentors across three Norwegian nursing homes. The transcribed interviews were thematically analysed. Standards for reporting qualitative research were followed. RESULTS: The analysis yielded one pre-mentoring theme: (1) predominant enthusiasm and satisfaction and three post-mentoring themes: (2) enhanced confidence and motivation, (3) enhanced mentoring competence in supporting the nursing students' learning process, and (4) factors influencing the value-in-use of the digital educational resource. CONCLUSIONS: Digital educational resources support effective mentorship practices by enhancing the confidence and motivation in the mentor role and by enabling more goal-oriented supervision and assessment tailored to the learning goals of students. The implementation of digital educational resources to support and enhance effective mentorship practices is an important avenue for further research towards achieving high-quality learning environments in clinical nursing education in general and nursing homes. Based on the study findings, nursing educational institutions should consider offering digital educational resources to develop, support, and advance mentorship training, which may more effectively impact and improve the quality of clinical nursing education.

Co-creating digital educational resources to enhance quality in student nurses' clinical education in nursing homes: Report of a co-creative process.

AIM: To report a methodological, co-creative approach for developing an interactive digital educational resource to enhance the quality of student nurses' clinical education in nursing homes and to elucidate the lessons learned from this approach. DESIGN: This study applied a co-design methodology that builds on participatory design principles. METHODS: Co-creating the digital educational resource included multiple sequential and interactive phases inspired by the design thinking framework. Workshops were employed as the primary co-creative activity. RESULTS: Seven separate homogenous or joint heterogeneous workshops were conducted with student nurses, nurse educators, registered nurse mentors and e-learning designers (n = 36) during the active stakeholder engagement phases to inform the educational content, design and functionality of the digital educational resource. These were informed by, and grounded in, learning theory and principles. CONCLUSION: Co-creative approaches in nursing education are an essential avenue for further research. We still lack systematic knowledge about the impact and benefits of co-created initiatives, stakeholders' motivations, barriers, facilitators to participation and the role of context in supporting effective co-creative processes to increase the quality of nursing education. IMPACT: This paper demonstrates how digital educational initiatives to enhance quality in clinical nursing education can be co-created with key stakeholders through a novel methodological approach inspired by design thinking. To date, the methodological development process of co-created educational interventions has received limited attention and compared with the content and theoretical underpinnings of such interventions, has rarely been addressed. Therefore, this paper facilitates knowledge exchange and documents vital aspects to consider when co-creating digital educational initiatives incorporating multistakeholder perspectives. This promotes a stronger academic-practice partnership to impact and enhance the quality of clinical nursing education in nursing homes. PUBLIC CONTRIBUTIONS: Student nurses, nurse educators, and registered nurse mentors worked alongside researchers and e-learning designers in the co-creative process.

Nurse educators' suggestions for a digital educational resource suitable for undergraduate student nurses' placement studies: Qualitative empirical research.

AIMS: To explore and describe nurse educators' suggestions regarding a digital educational resource addressing quality in placement studies for first-year student nurses in nursing homes. DESIGN: A qualitative, explorative, and descriptive research design. METHODS: Focus group interviews with eight nurse educators and individual interviews with six nurse educators. The interviews were audio-recorded and transcribed verbatim; subsequently, data were analysed in lines with content analysis as described by Graneheim and Lundman. RESULTS: The analysis revealed three main categories: 'Suggestions for a digital educational resource to strengthen and support nurse educators' role in follow-up students', 'Suggestions for a digital educational resource to complement and support interaction between stakeholders in placement', and 'Suggestions for a digital educational resource to facilitate student nurses' learning processes'. The categories were captured by the overarching theme, 'A digital educational resource facilitating interaction between stakeholders and students' learning processes. CONCLUSION: This study revealed nurse educators' suggestions regarding design elements, content, and use of a digital educational resource addressing placement studies for first-year student nurses' in nursing homes. Implications for the profession and/or patient care: Nurse educators should be involved in designing, developing, and implementing digital educational resources aiming to support student learning in nursing education placement studies. IMPACT: This study explored nurse educators' suggestions for a digital educational resource. They suggested a digital educational resource to strengthen and support their role, support interaction between stakeholders, and facilitate student nurses' learning processes. Further, they suggested a digital educational resource to be used as a supplement rather than as a replacement for nurse educators' physical presence in placements. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research reporting guidelines were used. No Patient or Public Contribution.

Registered nurse mentors' experiences from co-creation in higher education targeting enhancement of mentorship practices in nursing homes: A qualitative study.

AIM: To explore registered nurse (RN) mentors' experiences of participating in the co-creation of a digital educational resource intended to enhance mentorship practices of first-year nursing students in clinical placement in nursing homes. DESIGN: An interpretive, descriptive qualitative study design. METHODS: Data were collected through two focus group interviews with 15 RN mentors (n = 15) participating in co-creative workshops. The co-creative process entailed four co-creative workshops conducted over a 17-month period (June 2019 to end of Oct 2020). Focus group interviews were conducted following the second and third workshops (i.e., in Dec 2019 and in Oct 2020) and data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to report the findings. RESULTS: The analysis identified three themes: (1) co-creative reflective dialogues contributed to knowledge development and increased motivation among mentors; (2) the co-creative approach facilitated and validated the nursing academic-practice tripartite partnership; and (3) effectiveness of workshop structure in facilitating collaboration and mitigating power inequities. CONCLUSION: A co-creative process provides notable opportunities to advocate for mentorship needs and to enhance mentorship practices in nursing homes. IMPACT: Our study adds to the evidence on co-creation in nursing education, providing insights on the co-creative process and methodology. Higher Education Institutions are uniquely positioned to act as a co-creative arena for the academic-practice collaboration and for the development of educational resources within nursing education. Co-creation may facilitate stronger academic-practice partnership that may more effectively impact mentorship practices in nursing homes and health care system effectiveness. PUBLIC CONTRIBUTIONS: The RNs included in the study were involved in the co-creative process as active contributors informing the digital educational resource content and design.

Learning in nursing home placement: A phenomenological study of student nurses' lived experience.

AIM: To explore first-year student nurses' lived experience of learning in clinical placement in nursing homes. BACKGROUND: Nursing homes traditionally represent students' first clinical placement sites during nurse education, and nursing home residents' care needs can provide opportunities for student nurses to acquire both fundamental and specialised nursing skills. In clinical placements, students have opportunities to apply and integrate theoretical knowledge, practical skills and ethical competence in a clinical setting. DESIGN: A qualitative design with a hermeneutic phenomenological approach was employed and reported in accordance with the COREQ guidelines. METHODS: The study was undertaken at three nursing homes affiliated with one Norwegian university. Close observation (173 h) and in-depth individual interviews (n = 7) with first-year student nurses were conducted to explore their lived experience of learning. Data analysis was guided by van Manen's hermeneutic phenomenological approach. RESULTS: The essential meaning of the phenomenon of learning in clinical placements in a nursing home setting is characterised by four themes: (1) navigating a new and complex learning context, (2) being emotionally affected when facing sickness and frailty, (3) having a vital need for support and guidance and (4) being engaged in learning. CONCLUSIONS: The findings are discussed against the backdrop of educational learning theory. Learning in clinical placements in nursing homes is a multi-faceted and complex phenomenon related to the students' lived experience on the contextual, relational and individual levels. Overall, our findings demonstrate that learning in clinical placements is part of the process of professional identity development. RELEVANCE TO CLINICAL PRACTICE: The clinical practice arena should emphasise emotional support for student nurses, enhance their self-directed reflection and explicitly focus on the essence of nursing in nursing homes.

Exploring the formal assessment discussions in clinical nursing education: An observational study.

INTRODUCTION: According to EU standards, 50% of the bachelor education program in nursing should take place in clinical learning environments. Consequently, this calls for high quality supervision, where appropriate assessment strategies are vital to optimize students' learning, growth, and professional development. Despite this, little is known about the formal assessment discussions taking place in clinical nursing education. OBJECTIVE: The aim of this study was to explore the characteristics of the formal assessment discussions taking place during first-year students' clinical education in nursing homes. METHOD: An exploratory qualitative study was performed. The data consist of passive participant observations of 24 assessment discussions (12 mid-term and 12 final assessments) with first-year nursing students (n=12), their assigned registered nurse mentors (n=12) and nurse educators (n=5). The study was conducted in three public nursing homes in a single Norwegian municipality. Data were subjected to thematic analysis. The findings were reported using the Standards for Reporting of Qualitative Research. RESULTS: Three themes were identified regarding the characteristics of the formal assessment discussions: (1) adverse variability in structuring, weighting of theoretical content and pedagogical approach; (2) limited three-part dialogue constrains feedback and reflection; and (3) restricted grounds for assessment leave the nurse educators with a dominant role. CONCLUSION: These characteristic signal key areas of attention to improve formal assessment discussions to capitalize on unexploited learning opportunities.

Exploring mentorship practices in clinical education in nursing homes: A qualitative mixed-methods study.

AIMS AND OBJECTIVES: To explore registered nurses' mentorship practices of first-year nursing students in nursing home placements. BACKGROUND: Enabling nursing students to develop professional competence through clinical placements relies heavily on registered nurses' mentorship practices. Despite renewed interest in nursing homes as an important clinical placement setting, studies are scarce on registered nurses' mentorship practices in this context. DESIGN: An exploratory, qualitative mixed-methods design. METHODS: The data consisted of 126 h' observation of two registered nurse mentor-student dyads, supplemented by in-depth interviews (n = 12) with registered nurse mentors. The data were collected in three Norwegian nursing homes and analysed using content analysis. The consolidated criteria for reporting qualitative research (COREQ) checklist were used to report the findings. RESULTS: The registered nurses' mentorship practices of first-year nursing students in nursing home clinical placement were characterised by (1) variability and uncertainty in pedagogical supervisory approaches, (2) lack of management support and engagement of staff members in supervision, (3) lack of supervisory continuity and (4) a peripheral role in formal assessment discussions. CONCLUSIONS: A marginal nursing home context, alongside a mismatch between registered nurses' roles and first-year students' learning objectives, introduces considerable vulnerability that impedes effective mentorship practices. Targeted efforts to enhance mentorship practices in nursing homes are warranted to promote full use of the learning potential in this context. Developing and testing educational interventions is necessary to effectively enhance registered nurses' pedagogical competence, alongside engagement and support from nurse managers and nurse educators. RELEVANCE TO CLINICAL PRACTICE: This study provides insight into barriers to effective mentorship practices of first-year nursing students in nursing home placements. These barriers warrant attention from nursing home managers and nurse education institutions towards improvements that enhance effective mentorship practices vital for students' learning, professional growth and future recruitment to care for older people.

Nursing students' experience with clinical placement in nursing homes: a focus group study.

BACKGROUND: A renewed interest in nursing homes as clinical placement settings for nursing students has been prompted by the growing healthcare needs of an ageing population. However, if future nurses are to be enthusiastic about working in this healthcare context, it is essential that higher education institutions that educate nurses and nursing homes that provide placement experiences to students do so with a supportive, positive, and enriched approach. METHODS: To explore first-year nursing students' placement experience in nursing homes, we conducted an exploratory qualitative study in three city-based nursing homes in western Norway. Thirteen first-year nursing students participated in the study. Three focus group interviews were conducted to explore the students' placement experiences. Data were analysed using thematic analysis. The findings were reported using the Standards for Reporting Qualitative Research (SRQR). RESULTS: The analysis describes five themes relating to first-year students' placement experience in nursing homes; (1) variations in utility of pre-placement orientation and welcome at placement site; (2) a challenging learning environment; (3) spending considerable placement time with non-registered nurses; (4) considerable variability in supervision practices; and (5) a vulnerable and demanding student role. CONCLUSIONS: The research provides insight into the contextual characteristics encountered by first-year students that influence the quality of their placement experiences. Consequently, these characteristics impede access to important role models who lend support to a student's growth and professional development, preventing full utilisation of the learning potential offered in nursing homes. Hence, we propose that targeted efforts are warranted to foster positive placement experiences and enhance students' clinical education in nursing homes.

Enhancing student nurses' clinical education in aged care homes: a qualitative study of challenges perceived by faculty staff.

BACKGROUND: Ageing populations are increasing the demand for geriatric care services. As nursing schools respond to this demand, more high-quality clinical placements are required, and aged care homes offer suitable placement sites. Although an aged care experience for students is beneficial, the basis for effective implementation of these placements is yet to be fully established. The aim of this study was to explore faculty staff perspectives on the challenges associated with providing effective clinical education in aged care homes for first-year student nurses. METHODS: An exploratory qualitative study was performed. Fifteen in-depth interviews were conducted with program leaders of nursing degree programs (n = 4), course leaders (n = 6) and practice coordinators (n = 5) in three Norwegian universities. Data were analysed using thematic analysis. The findings were reported using the Standards for Reporting Qualitative Research (SRQR). RESULTS: Five themes were identified regarding the perceived challenges to implementing effective clinical education in aged care homes: (1) low staffing levels of registered nurses limit the capacity to effectively host students; (2) prevalence of part-time teachers can compromise the quality of students' learning experiences; (3) tensions about the required qualifications and competencies of nurse teachers; (4) variation in learning assessments; and (5) lack of quality assurance. CONCLUSIONS: These challenges signal key areas to be addressed in quality assurance for effective aged care placements. Further research into the minimum staffing levels required to support student learning in the aged care setting is required. Methods for developing shared practices to facilitate learning in aged care homes need to address the prevalence of part-time teaching appointments. Further research into the levels of qualification and competence required to support student learning in aged care facilities can assist with setting standards for this sector. Finally, academic-practice institutions must engage with government officials and national nursing bodies to develop national standards for clinical education in aged care homes.

Improving quality in clinical placement studies in nursing homes (QUALinCLINstud): the study protocol of a participatory mixed-methods multiple case study design.

INTRODUCTION: Improved quality in clinical supervision and assessment of student nurses in nursing home clinical placements is vitally important to effective recruitment and preparation for this healthcare sector. Knowledge regarding supervision and assessment practices within these settings is limited. Also, knowledge of evolving e-learning tools on the quality and effectiveness of these educational practices seems to be absent. METHODS AND ANALYSIS: The aim of the "Improving quality in clinical placement studies in nursing homes" (QUALinCLINstud) study is to develop and evaluate how a web-based programme can optimise supervision, assessment and learning during nursing home placements. The study applies a participatory, mixed-methods case study design, organised in four work packages (WPs). WP1 will explore how the nurse education institution address the quality of student nurses' clinical placements in nursing homes. In WP2, clinical supervision and assessment practices will be explored, and described from multiple stakeholder perspectives. In WP3, based on the findings from WP1 and WP2, a web-based pedagogical supervision and assessment programme will be developed through a developmental co-productive process between nurse education institutions, practice settings and student nurses. In WP4, the web-based programme will be pilot-tested and evaluated through a mixed-methods approach. A range of data collection procedures will be used throughout the project, for example, questionnaires, interviews, observations and workshops. ETHICS AND DISSEMINATION: The ethical conduct of the study is approved by the Norwegian Centre for Research Data (2018/61309 and 489776). The results will be disseminated through scientific articles, three PhD theses, presentations at national and international conferences, and through publicly accessible trade journals and newspapers. The results will generate knowledge to inform supervision and assessment practices in nursing home placements. Moreover, the study will generate knowledge concerning the developmental process of a web-based supervision and assessment programme, and the value of e-learning tools applied in clinical nursing education.

An observational study of older patients' participation in hospital admission and discharge--exploring patient and next of kin perspectives.

AIMS AND OBJECTIVES: To explore older patients' participation during hospital admission and discharge. BACKGROUND: Patient participation is suggested as a means to improve the quality of transitional healthcare. Older people with chronic diseases, physical disabilities and cognitive impairments often need to transfer from primary to hospital healthcare and vice versa. DESIGN: This study adopts a participant observational research design. METHODS: Participant observations of 41 older patients (over 75 years of age) during hospital admission and discharge were conducted in two hospitals in Norway (in 2012). The observations included short conversations with the patient and their next of kin to capture their participation experiences. Systematic text condensation was used to analyse the data material from the field notes. RESULTS: Varying degrees of information exchange between healthcare professionals and patients, and a lack of involvement of the patient in decision-making (in admission and discharge) were observed and experienced by patients and their next of kin. The next of kin appeared to be important advocates for the patients in admission and provided practical support both during admission and discharge. Data suggest that patient participation in admission and discharge is influenced by time constraints and the heavy workloads of healthcare professionals. Patients' health conditions and preferences also influence participation. CONCLUSIONS: Several issues influence the participation of the older patients during hospital admission and discharge. Participation of the older patients needs continuous support from healthcare professionals that acknowledges both the individual patient's preferences and their capacity to participate. RELEVANCE TO CLINICAL PRACTICE: Study findings report discrepancies in the involvement of older people and their next of kin. There is a need to increase and support older patients' participation in hospital admission and discharge.

Hospital discharge of the elderly--an observational case study of functions, variability and performance-shaping factors.

BACKGROUND: Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin). METHODS: The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours' observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge. RESULTS: We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor's specialization) and regulatory influences (financial incentives). CONCLUSIONS: The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions.

Quality in transitional care of the elderly: Key challenges and relevant improvement measures.

INTRODUCTION: Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures. METHODOLOGY: Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers. RESULTS: SIX MAIN CHALLENGES WITH BELONGING DESCRIPTIONS HAVE BEEN IDENTIFIED: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others' roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment). CONCLUSION: Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.

Quality and safety in transitional care of the elderly: the study protocol of a case study research design (phase 1).

INTRODUCTION: Although international studies have documented that patients' transitions between care providers are associated with the risk of adverse events and uncoordinated care, research directed towards the quality and safety of transitional care between primary and secondary health and care services, especially for the elderly receiving care from multiple healthcare providers due to complex health problems, is lacking. This study investigates how different aspects of transitional care can explain the quality and safety of elderly healthcare services in Norway. The overall aim of the study was to explore different aspects of transitional care of the elderly, in different contexts and how they might explain the quality and safety of care. METHODS AND ANALYSIS: The study applies a case study design. Two cases are chosen: one city-based hospital and one rural hospital with associated nursing homes and home-based nursing services. Admission and discharge to/from hospital to/from nursing homes or home-based nursing services constitute the main focal areas of the study, including the patient, next-of-kin and the professional perspective. The qualitative methods employed include participant observation, individual interviews and document analysis. To ensure trustworthiness in the data analysis, we will apply analyst triangulation and member checks. A total impression of the data material will first be created in a systematic text condensation approach. Second, the qualitative data analysis will involve in-depth analyses of two specific themes: the risk perspective and the patient perspective in transitional care. ETHICS AND DISSEMINATION: The study is approved by the Norwegian Regional Committees for Medical and Health Research Ethics. The study is based on informed written consent, and informants can withdraw from the study at any point in time. Interview and observation data material will be managed confidentially. RESULTS: It will be disseminated at research conferences, in peer-reviewed journals and through public presentations to people outside the academic community.

Interventions to improve patient safety in transitional care--a review of the evidence.

When a patient's transition from the hospital to home is less than optimal, the repercussions can be far-reaching - hospital readmission, adverse medical events, and even mortality. Elderly, especially frail older patients with complex health care problems appear to be a group particularly at risk for adverse events in general, and during transitions across health providers in particular. We undertook a systematic review to identify interventions designed to improve patient safety during transitional care of the elderly, with a particular focus on discharge interventions. We searched the literature for qualitative and quantitative studies on the subject published over the past ten years. The review revealed a set of potential intervention types aimed at the improvement of communication that contribute to safe transitional care. Intervention types included profession-oriented interventions (e.g. education and training), organisational/culture interventions (e.g. transfer nurse, discharge protocol, discharge planning, medication reconciliation, standardized discharge letter, electronic tools), or patient and next of kin oriented interventions (e.g. patient awareness and empowerment, discharge support). Results strongly indicate that elderly discharged from hospital to the community will benefit from targeted interventions aimed to improve transfer across healthcare settings. Future interventions should take into account multi-component and multi-disciplinary interventions incorporating several single interventions combined.