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The Varying Roles of Nurses During Interfacility Care Transitions

Jeffs, Lianne, PhD, RN, FAAN; Saragosa, Marianne, MN, RN; Law, Madelyn, PhD; Kuluski, Kerry, PhD, MSW; Espin, Sherry, PhD, RN; Parker, Heidi, BSc, MT; Collins, Kristen, BA

doi: 10.1097/NCQ.0000000000000248

This study explored health care professionals' perceptions and experiences associated with the role of point-of-care nurses during care transitions from an acute care hospital to a rehabilitation setting to being discharged home. We used a qualitative exploratory design and semistructured interviews. Content analysis revealed 3 themes that point to the ambiguity related to the roles that nurses enact with older patients during care transitions. We suggest ways to better support nurses to engage in quality care transitions.

Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada (Dr Jeffs); St Michaels Hospital, Toronto, Canada (Dr Jeffs and Mss Saragosa, Parker, and Collins); Department of Health Science, Brock University, St Catharines, Ontario, Canada (Dr Law); Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada (Dr Kuluski); and Daphne Cockwell School of Nursing, Ryerson University, Toronto Ontario, Canada (Dr Espin).

Correspondence: Lianne Jeffs, PhD, RN, FAAN, Li Ka Shing Knowledge Institute, 209 Victoria St, Toronto, ON M5B 1T8, Canada (

Funding for this study was from the Ontario Ministry of Health and Long-Term Care.

The authors declare no conflict of interest.

Accepted for publication: January 10, 2017

Published ahead of print: February 16, 2017

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