Mid Sweden University

Background: Care transitions from hospital to home are critical phases for older adults. In Sweden, when home healthcare is needed after discharge, the care transition involves a transition from regional to municipal care, constituting a change of principal care provider. Healthcare in rural areas is impacted by long travel times and limited availability of healthcare services. These conditions increase patient vulnerability and complicate the delivery of safe and coherent care.

Aim: The primary objective of this thesis was to generate a comprehensive, in-depth understanding of the organization of transitions from hospital to home in rural areas, with a specific focus on how the quality of care is experienced and addressed.

Methods: This thesis utilized an exploratory and explanatory design, built upon qualitative data, across four studies to investigate rural care transitions from three perspectives: registered nurses, nursing leaders, and older adults. Constructivist grounded theory (Studies I and III) and Reflexive thematic analysis (Studies II and IV) were utilized to investigate how care transitions are enacted, shaped, and experienced.

Results: Across the studies, rural circumstances could imply both hindrances and facilitators for care transitions. Structural conditions, such as long distances and limited staffing, hindered the continuity and safety of rural care transitions. In contrast, rural conditions, such as social networks and close-knit relationships within rural communities, fostered continuity and quality. Registered nurses proactively anticipated care needs, addressed information gaps, and navigated structural limitations by planning discharge timing, training municipal staff, and coordinating patient follow-up despite significant travel distances. In the absence of shared inter-organizational quality goals or collaboration arenas, nursing leaders focused on implementing unit-level strategies related to competence, staffing stability, and care flow. The experiences of older adults highlight the dual nature of care transitions, defined by both the physical relocation and an intense emotional and existential process. This process is shaped by their ability to effectively navigate care, manage uncertainty, and leverage social support. Synthesized through Meleis’s Transition Theory and Donabedian’s quality framework, the findings highlight the interaction between rural structures, professional processes, and the outcomes in shaping the perceptions of care transition quality.

Conclusions: Improving rural care transitions requires organizational recognition of rural contextual challenges, strengthened cross-boundary collaboration between regional and municipal caregivers, and sustained support for nurses’ coordinative roles. This thesis contributes novel insights by theorizing compensatory professional work as a key mechanism for sustaining quality amid rural constraints. It highlights nursing leadership as a largely overlooked dimension of care transitions, while demonstrating the importance of relational and emotional continuity for older adults in rural hospital-to-home transitions.