出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction: Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains.
Challenges: In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be ‘ready to be discharged’.
Discussion: We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.
