A Nurse-Led Cross-Sectoral Home-Based Follow-Up Visit for Older Patients Discharged From the Hospital: A Practice Research Project

AIM: We aimed to explore hospital-based nurses' experiences and perspectives on their conduct of clinical nursing practice through 12 months of 'cross-sectoral home-based follow-up visits' for older patients discharged from hospital to home care. DESIGN: This study is theoretically and methodologically grounded in critical psychological practice research. METHODS: We conducted 11 co-researcher meetings with 5 hospital-based nurses over 12 months, exploring changes and dynamics over time. Data were analysed with the condition, meaning and reasoning analysis. RESULTS: We identified four themes: (1) Evolving nursing practice and care, (2) Instrumental nursing influenced care over time, (3) Development of caring communities as a bridge between healthcare sectors and (4) Being in the patient's home transforms nursing and care. CONCLUSION: The hospital-based nurses significantly enhanced their competencies over the 12 months of conducting cross-sectoral home-based follow-up visits. Engaging with the patients in their homes allowed the hospital-based nurses to develop their sensitive and sensory awareness. The embodied knowledge gained through these experiences improved their approach to transitional care and influenced and evolved their nursing practice within the hospital setting and care provided to older patients. PATIENT OR PUBLIC CONTRIBUTIONS: Hospital-based nurses were enrolled in data collection and data analysis.