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Purpose: The overall purpose of this project was to explore the transition into long-term care placement for older residents from different perspectives in order to maintain and enhance health and well-being, and inform practice and improve care. Methods: An ethnographic design used three sources of data, periodic participating observations, individual semi-structured interviews, and reading of relevant documents. The project comprises three studies. The aim of study I was to describe and explore the experiences of next of kin during the older residents’ transition into long term care placement. I interviewed ten next of kin to eight newly admitted residents. The next of kin talked about their experiences during the preparation period, the arrival day, and the first week after placement. The aim of study II was to explore and describe the staff’s actions during the initial transition process for the older residents into long-term care facility. In study III, the aims were to explore and describe the staff’s interactions during the older residents’ transition into long-term care facility, and explore how the staff interactions may influence their assistance and care of the older residents. In studies II and III, I followed through periodic participating observations, the staff who assisted ten new residents during the preparation period, arrival day, and the first week after placement. Moreover, I interviewed sixteen staff and the leader of the institutional services, and read relevant documents. Thematic analyses were used to analyze the data in studies I and III and content analysis inspired the analysis of study II. Main findings: What happened prior to the long-term care placement as well as what happened in the initial period in the nursing home influenced the experiences of the next of kin and relationships within the family (I). Moreover, it influenced staff’s actions and interactions, which ultimately influenced the older residents’ transition processes (II, III). The next of kin strove to handle the new situation. They kept on feeling responsible for their older family member, and provided continuity with their past life. Structural arrangements, such as the older family member having to share a private room with a co-resident and being moved about in the nursing home frustrated the next of kin. They did not expect much for themselves, apart from staff notice them and approach them during visits. This seldom happened, and they experienced little support from the staff (I). The next of kin and the staff were distant to each other and members from both groups expected the other to approach them. They appeared shy towards each other in this rural community where they knew of each other. In study II, staff’s actions varied from involvement with the new resident to ignorance. Some powerful influential forces on their actions were the management of the facility, individual staff’s formal position, traits, and enthusiasm, resident and staff mix, and local transparency. Both licensed and unlicensed staff were susceptible of performing poor assistance towards the new residents, which may contribute to directing the new resident towards vulnerability and risk. In study III, the staff interactions influenced the new residents’ transition process in complex ways. This study captures some descriptions and connections between micro and macro levels, and some power mechanism at play among the participants that may contribute to enhancing or inhibiting a smooth transition for the older residents and their next of kin. Organizational structures, staff’s formal position, and informal staff alliances were complex and paradoxical. Some powerful influential forces on the staff’s interactions were the previous health care setting, the management of the facility, the strong oral culture, individual staff’s formal position, personality and authority, resident and staff mix, the physician’s round, local transparency, and the taken-for-granted. The findings demonstrate the significance of every agent in the organization, and how each one may influence the staff’s work in unpredictable ways. When happening, the spontaneous staff interactions were “pockets of excellence” and contributed to maintaining the evolving needs of the new residents in the initial period. These interactions depended on dedicated permanent staff who involved everybody present for the best of the new residents, and on the mix of staff at any given time. During holidays with many supply staff, the involved permanent staff were unable to perform their work according to their own standards. Especially the part-time unlicensed supply staff seemed prone at disturbing the work of most permanent staff. Conclusion: Main areas of concern regarding both the next of kin and the staff were that they needed support and information, and clarify roles between them. Moreover, to maintain the health and well-being of the older residents and their next of kin during the transition involve focus on the playing out of power in staff actions and interactions. In this respect, this project shows some connections and dialectics between macro- and micro levels, which may influence on this: inter organizational level, organizational level, inter professional level, professional level and personal level, as well as contexts and circumstances at any given time. The findings show the importance of involving everybody to the best for the new resident and their next of kin. Combining complexity science with transition theory in nursing provide valuable insights for grass root-, management-, education-, research-, and policy levels how to improve the assistance of the older residents and their next of kin during transitions into longterm care placement. Digital fulltext not available

Background: Future challenges in many countries are the recruitment of competent staff in long-term care facilities, and the use of unlicensed staff. Our study describes and explores staff interactions in a long-term care facility, which may facilitate or impede healthy transition processes for older residents in transition. Methods: An ethnographic study based on fieldwork following ten older residents admission day and their initial week in the long-term care facility, seventeen individual semi-structured interviews with different nursing staff categories and the leader of the institution, and reading of relevant documents. Results: The interaction among all staff categories influenced the new residents’ transition processes in various ways. We identified three main themes: The significance of formal and informal organization; interpersonal relationships and cultures of care; and professional hierarchy and different scopes of practice. Conclusions: The continuous and spontaneous staff collaborations were key activities in supporting quality care in the transition period. These interactions maintained the inclusion of all staff present, staff flexibility, information flow to some extent, and cognitive diversity, and the new resident’s emerging needs appeared met. Organizational structures, staff’s formal position, and informal staff alliances were complex and sometimes appeared contradictory. Not all the staff were necessarily included, and the new residents’ needs not always noticed and dealt with. Paying attention to the playing out of power in staff interactions appears vital to secure a healthy transition process for the older residents. Keywords: Long-term care facility, Staff interactions, Transition, Complexity science, Resident, Ethnography. © 2015 Eika et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Bakgrunn: Denne studien belyser erfaringer sykepleiere på helsehus og hjemmesykepleien har, knyttet til pasientoverganger mellom hjemmet og helsehuset. Det er mindre forskning gjort i Norge som ser på planlagte pasientoverganger innad i kommunehelsetjenesten. Studier har vist at god kommunikasjon mellom helsepersonell er avgjørende for å sikre at nødvendig informasjon om pasientene deles mellom de ulike nivåene, og på den måten er med på å sikre en god pasientovergang. En ny norsk studie viser at det gjøres et omfattende informasjonsarbeid knyttet til pasientoverganger innad i kommunen. Hensikt: Den overordnede hensikten med denne masteroppgaven er å bedre pasientovergangene mellom hjemmet og helsehuset i kommunen jeg arbeider. Gjennom å tilegne meg kunnskap om hva andre sykepleiere erfarer, knyttet til samarbeid innad i kommunehelsetjenesten ønsker jeg å få mer kunnskap, som kan overføres til eget arbeidssted. Problemstilling: «Hvilke erfaringer har sykepleiere i kommunehelsetjenesten knyttet til pasientoverganger mellom hjemmet og helsehuset?» Forskningsspørsmål: 1) Hva kjennetegner samarbeidet mellom sykepleierne i hjemmesykepleien og på helsehuset? 2) Hvilke faktorer legger sykepleierne særlig vekt på, for å fremme samarbeidet i pasientovergangene? 3) Hvilke faktorer erfarer sykepleierne kan hemme eller være til hinder for samarbeidet i pasientovergangene? Dette er kunnskap som kan være med på å bedre pasientovergangene for eldre i kommunehelsetjenesten. Teoretisk referanseramme: Den teoretiske referanserammen for denne masteroppgaven er nært knyttet til min sykepleiefaglige forforståelse, og legger vekt på teori om kommunikasjon, samarbeid, pasientsikkerhet, pasientoverganger, transition teori i sykepleie og faglig forsvarlighet. Metode: Studien har et kvalitativ design. Det ble anvendt to fokusgruppeintervju med til sammen syv deltagere. Ett med fire sykepleiere fra hjemmesykepleien og ett med tre sykepleiere fra helsehus. Analysen er gjennomført ved tematisk innholdsanalyse og i tråd med Malteruds fire trinn. Studien er godkjent av NSD. Forskningsetiske overveielser er ivaretatt gjennom hele forskningsprosessen. Resultater: Funnene indikerer kommunikasjonsutfordringer i pasientovergangene, uavklarte roller, forventninger og tilnærminger i pasientovergangene påvirker samarbeidet mellom sykepleierne på helsehuset og i hjemmesykepleien. Og at kontekst, rammebetingelser og relasjoner påvirker samarbeidet i pasientovergangene. Diskusjon: I diskusjonsdelen løftes problematikken og dilemmaer fra resultatdelen frem og drøftes i lys av tidligere forskning, nasjonale føringer, lovverk og annen relevant teori. Konklusjon: Studien hadde tynne og overfladiske data. Sykepleierne legger større vekt på hva som hemmer, enn det som fremmer samarbeidet i pasientovergangene mellom helsehuset og hjemmet. Kommunikasjonsutfordringer lyser særlig frem som et komplekst og sentralt område. Sykepleierne beskriver kommunikasjonsutfordringer som hemmende for samarbeid i pasientovergangen. Helsehuset trekker frem at det å kjenne den man skal samarbeide med i hjemmesykepleien kan fremme samarbeidet i pasientovergangene. Samarbeidet mellom sykepleierne i hjemmesykepleien og på helsehus i denne studien kjennetegnes av ulike rutiner vedrørende kommunikasjon i pasientovergangene, uavklarte roller, forventninger og tilnærminger i pasientovergangene, kontekst, rammebetingelser og relasjoner. Nøkkelord: Erfaringer, sykepleiere, samarbeid, pasientoverganger & kommunehelsetjenesten. Background: This study sets out to shed light on the experiences nurses, working both at health care senters and in home nursning, have in regards to patient transition between their home and health care center. There have been smaller studies in Norway that looks at planned patient transfers within the municipal health service. Studies have shown that good communication between health personnel is crucial to ensure that the necessary information about a patients health is shared between the different levels of care, which again ensures good patient transfers. Intent: The overall purpose with this mater´s thesis is to help better the patient transfers between the patients home and the health care center where I work. By looking at what other nurses experience in collaboration within the municipal health service I hope to increase my level of knowledge, which then can be transfered to my workplace. Thesis: «Which experiences dose nurses in the municipal health service have linked to patient transfer between their home and a health care center?» Research questions: 1) What characterizes the collaboration between nurses working in home nursning and at the health care center? 2) Which factors is especially importantly to the nurses, to better the collaboration in regards to patient transfer? 3) Which factors does the nurses experience that mat inhabil or impede the collaboration in patient transfer. This is knowledge that would help better the patient transfer for the elders depending on the municipal health care. Theroretical frame of reference: The theroretical frame of reference in this master´s thesis is closely tied to my understanding of nursning, and emphasizes therory on communication, collaboration, patient safety, patient transfer, theories in nursning and professional justifiable. Method: This study has a qualitative design. There has been to focus group interviews with seven partisipants total. One of the group intervews had four nurses working in home nursning and three nurses working at a health care center. The analysis is completed by the thematic content analysis in line with Malterud four steps. The stydy is approved by NSD. Research ethics considerations has been maintained thorughout the reasearch process. Results: The findings indicate communication challenges during pasient transfers, unclear roles, a differences in expectations and approaches that affects the collaboration between nurses working with home nursning and at the health care center. The findings also discuss how context, conditions and relations also affects the collaboration regarding patient transfers. Discussion: The dillemmas and problematic areas found in the research portion is thourghly discussed in light of earlier studies, national guidelines, national laws and other relevant theory. Conclusion: The study had slim and superficial data. The nurses are more concerned with what is difficult, than what would help the collaboration between nurses working in home nursning and at the health care center. The study shows that communication challanges is epecially complex and sentral. The nurses describes how communication challenges workshop agains a produktive collaboration regarding patient transfers. Nurses at health care center says that it is easier to work togheter when they have a relationship with the nurse working in home nursning, especially during patient transfers. The collaboration between nurses working with home nursning or at the health care center is caractererized by different rutines regarding communication with patient transfers, unclear roles, different expectations and approaches, as well as context, conditions and relations. Key Words: Experiences, nurses, collaboration, patient transfers and municipal health care.