Developing nurses' transitional care for older adults through expansive learning actions.

Education of healthcare professionals is considered an important means for improvement of transitional care for older adults. Transitional care is often hampered by a fragmented organisation of healthcare and nurses functioning in silos with separate organisational cultures, which can lead to break downs in care and communication. Literature shows that there is a general lack of transitional care education. On this background, the aim of this PhD project was to investigate nurses' learning processes in transitional care for older adults through by conducting four studies.
The first study was a literature review of non-formal patient handover education drawing on scoping review methodology. The results showed a research gap and that literature is scarce, heterogeneous and mainly approaches learning as individuals' acquisition of competencies. Furthermore, the results showed that there is a lack of connection between learning and patient outcome as well as an absence of descriptions of notions of learning.
To address the research gap, in the second study, I developed and conducted a learning intervention drawing on Cultural Historical Activity Theory, focused ethnography, videography and the change laboratory method. Eighteen healthcare professionals, three patients and their families were included in the development of the learning intervention and 16 nurses were included in the learning intervention. The learning intervention resulted in a new transitional care model based on the nurses' attempts to resolve interconnected systemic contradictions. These included the contradiction between task-oriented nurses on the one hand and nursing ideals on the other hand, and the contradiction between nurses motivated by fulfilling bureaucratic and management goals on the one hand and older adults' needs for coherent care on the other hand. The model featured a person-centred approach towards older adults' transitions, a reinforcement of frontline nurses' role in transitional care and suggestions of how to operationalise a person-centred approach.
The third study contributed knowledge of how nurses expanded their understanding of challenges in transitional care to be caused by systemic contradictions enabling them to identify a need for development. This included a need to involve patients and their next of kin and to emphasise relational care in transitional care.
The fourth study contributed knowledge of how nurses' transformative agency emerged from initial critique of the conditions to provide transitional care to the collective envisioning of a transitional care model. The emergence of collective transformative agency was nurtured by the confrontation with and the possibility to voice practice-based challenges as well as the recognition of a need for development of transitional care. Furthermore, it was nurtured by nurses' employment of professional nursing identity as a mediating artefact.
All together, the PhD project reveals a research gap in transitional care learning and offers a new approach to learning which addresses the complexity of practice and involves nurses as contributors to development of practice. Furthermore, the project contributes knowledge of nurses' learning and how this learning can be linked to the development of transitional care.