Communication and coordination during transition of older persons between nursing homes and hospital still in need of improvement.

Aim To investigate registered hospital and nursing home nurses' experiences of coordination and communication within and between care settings when older persons are transferred from nursing homes to hospital and vice versa. Background It has previously been reported that transfers to hospital from nursing homes and discharge of patients from hospital are surrounded by communication difficulties. However, studies focusing on both hospital and nursing home registered nurses' experiences of communication and coordination within and between nursing homes and hospitals are uncommon. Design A descriptive study design with a qualitative approach was used. Methods In 2008, three focus group discussions were conducted with registered nurses from hospitals and nursing homes (n=20). Data were analysed using content analysis. Results Nursing home registered nurses found it difficult to decide whether the older person should be referred to hospital from the nursing home. Hospital registered nurses reported often trying to stop premature discharges or having to carry out the discharge although it had not been fully prepared. Both hospital and nursing home registered nurses suggested increased collaboration to understand each other's work situation better. Conclusion Communication and coordination among hospital and nursing home registered nurses need to be furthered improved. Registered nurses' coordination and planning in the nursing home are extremely important to future elder care. We recommend that the medical care plan be regularly updated and meticulously followed, the aim being to reduce the risk of inappropriate medical treatment and nursing care and unnecessary transfer and admission to hospital.