Position, Responsibilities and Practice Interventions Relevant for Danish Transitional Care Nurses to Perform During Discharge of Older People: Delphi Survey

ABSTRACT

Aim

To determine expert clinicians' consensus opinion on the position, responsibilities and practice interventions relevant for hospital‐employed Transitional Care Nurses (TCNs) to perform a successful discharge process of older people with multi‐morbidity and transition to home.

Design

A two‐round Delphi survey.

Methods

An expert panel of 54 TCNs from five hospitals and 11 municipalities in a rural Danish region was invited to participate in the two Delphi rounds. The Delphi survey was developed using four key sources of data. The final questionnaire consisted of 120 items. The experts evaluated the relevance of the items in two rounds performed in September 2024.

Results

In the first Delphi round, 40 (74.1%) of the 54 experts replied to the questionnaire. Consensus agreement of ≥ 75% relevance (4–5 Likert) was found in 60 of the 120 items. In the second Delphi round, 57.4% of the 54 experts responded. Of the remaining 60 items, four items were evaluated as less relevant and were therefore excluded. The experts consented on the final relevance of 56 items.

Conclusion

Coordination and continuity of the discharge process combined with a high level of teamwork and collaboration with the patients, their relatives, and interdisciplinary colleagues at the hospital and in the municipality were rated as the most relevant responsibilities and practice interventions for the TCNs.

Implications and Impact

Inadequate description of Danish TCN's function may affect the planning and safety of older patients' transition. Consensus agreement was reached on 56 items addressing TCNs' position, responsibilities and practice interventions essential for older patients' transition. Knowledge will be used further to strengthen the Danish TCN's function.

Reporting Method

We have adhered to the ‘Guidance of Conducting and REporting of DElphi Studies’ (CREDES).

Patient or Public Contribution

No patient or public contribution.

Summary.

• Clarifying Transitional Care Nurses' (TCNs) position, responsibilities, and practice interventions is important for them to coordinate the complex care transitions of older patients with multi‐morbidity across hospital and municipality settings.

• Knowledge consensus of the expert will be a baseline for further development and strengthening of the TCNs' work with transitions.

• The Delphi survey showed how the experts agreed on the relevance of administrative nursing tasks of coordination and continuity in the TCNs' work as well as collaboration and teamwork during the transition.

1. Introduction

Older people with multi‐morbidity require a comprehensive and coordinated discharge in their transition from hospital to home due to their complex care needs and various contacts across the healthcare system (Liang et al. 2021; Liebzeit et al. 2021). Structured transitional care interventions are essential, and the literature provides a multitude of evidence examples on nursing elements relevant to performing a complex discharge (Morkisch et al. 2020; Parker et al. 2020; Naylor et al. 2018). The intervention elements focus on the overall coordination of care and involve the engagement of patients and caregivers in care planning while creating and maintaining a strong relationship with them (Morkisch et al. 2020; Parker et al. 2020). Connecting patients and caregivers to community services and securing the collaboration between patients, caregivers, and community care teams is another important focus, along with educating patients and caregivers in self‐management and empowerment (Morkisch et al. 2020; Parker et al. 2020).

Explicit and essential interventions concerning transitional care have been described in various international settings. Two discharge interventions were found from the UK and Australia. The Discharge 2 Home programme from the UK was established during the COVID‐19 pandemic to improve hospital capacity by facilitating a continuous patient flow with a specific focus on post‐discharge community care (Jeffery et al. 2023). The Australian Transition Care Programme (TCP) is a national intermediate care service aiming to optimise functional independence and delay entry to permanent care for older people leaving hospital (Cations et al. 2020). In the USA, Coleman et al.'s (2006) Care Transition Intervention is utilised to address potential threats to quality and safety during care transitions by facilitating a Transition Coach to encourage the patient and caregivers to assert a more active role during care transitions.

The intervention closest related to the role of Danish Transitional Nurses is the Transitional Care Model from the USA developed by Naylor et al. (2018) from Afaf Meleis' Theory of Transition (Meleis 2010). The Transitional Care Model contain ten interconnected nursing components that specifically target discharge transitions of older adults with multiple chronic conditions (Naylor et al. 2018). The model components target maintaining relationships with patients and caregivers; engaging patients and caregivers; educating/promoting self‐management; screening at‐risk older adults; collaborating with patients, caregivers, and teams; promoting continuity; coordinating care; and delivering services from hospital to home (Naylor et al. 2018). One of the essential nursing components in the Transitional Care Model (Naylor et al. 2018) is promoting continuity by ‘relying on Transitional Care Nurses’, to coordinate the transition related to the older patients' discharge. The main responsibilities of the TCNs included facilitating complex transitions between hospital and home‐based care to reduce adverse events, time use and costs (Naylor et al. 2018).

The Transitional Care Model has been rigorously tested and has consistently demonstrated effectiveness in transitional care for older adults with complex trajectories to prevent poor outcomes among at‐risk populations as they move from one level of care to another, among multiple providers and across settings (Naylor et al. 2018). Internationally, transitional care interventions have been applied with success to complex settings, such as mental healthcare (Tyler et al. 2019), patients with heart failure (Berre et al. 2017; Feltner et al. 2014), cognitive impairment and dementia (Naylor et al. 2016), chronically ill adults (Tyler et al. 2019), and discharge of older patients (Mora et al. 2017; Mabire et al. 2016). Significant positive effects have been found after implementing transitional care interventions, such as lower patient mortality (Liang et al. 2021; Feltner et al. 2014), reduced hospital readmission rate (Tyler et al. 2019), lower healthcare utilisation and emergency services (Naylor et al. 2011), decreased length of stay (Naylor et al. 2016), higher quality of life, and patient satisfaction (Mabire et al. 2016).

To support transitions between hospital and home for older patients with multi‐morbidity in Denmark, a function as TCN was introduced in a Danish university hospital in the year 2020. However, the position, responsibilities, and best practice interventions within the role of these TCNs were left undetermined, leaving the TCNs without precise directives regarding how to reduce adverse events and readmissions during discharge transitions. The inadequate description of the TCN's role in the Danish university hospital can undoubtedly create consequences for the older patients' discharge but also for coordination of their further care and treatment (Møller et al. 2022). As a first step towards developing evidence‐based knowledge, it is important to establish expert consensus regarding the TCN position, responsibilities, and best practice interventions for them to coordinate the complex care transitions among older patients with multi‐morbidity across hospital and municipality settings.

1.1. Aim

To determine expert clinicians' consensus opinion on the position, responsibilities, and practice interventions relevant for Danish hospital‐employed TCNs to perform a successful discharge process of older people with multi‐morbidity and transition to home.

2. Methods

2.1. Design

A Delphi survey (Keeney et al. 2006) was conducted to gain structured assessments and controlled feedback from expert clinicians on the position, responsibilities and best practice interventions of TCNs during the discharge transition process. Given the complexity and emerging nature of this role, establishing expert consensus was deemed an essential foundation for developing evidence‐based knowledge in this field. The study was performed following the ‘Guidance of Conducting and REporting of DElphi Studies’ (CREDES) (Jünger et al. 2017).

2.2. Participants

Participants in the expert panel for the Delphi survey were selected through convenience and purposive sampling (Polit and Beck 2018). The total population of 54 TCNs was recruited from five hospitals and 11 municipalities in a rural Danish region. The 54 TCNs were all part of a regional network of TCNs, which was the only inclusion criterion for recruitment. The first contact consisted of an e‐mail sent to the 54 selected TCNs, consisting of an invitation to participate and information about the Delphi survey aim.

2.3. The Delphi‐Questionnaire

2.3.1. Data Materials for Questionnaire Development

The questionnaire for the Delphi survey was developed using four key sources of information about the position, responsibilities and practice interventions of TCNs. The variations in data material were chosen to provide international and regional knowledge on the position, responsibilities, and practice interventions of TCNs in their work with complex discharge from hospital departments to municipality care settings for older people with multi‐morbidity.

2.3.1.1. A Questionnaire‐Based Cross‐Sectional Survey

A cross‐sectional survey describing and comparing the self‐reported characteristics of all.

TCNs employed in a university hospital in a rural Danish region and the six connected municipalities about their work areas, competencies, job satisfaction, and need for further training (Møller et al. 2023).

Results from the cross‐sectional survey provided data on:

• Responsibilities: promotion of continuity and being primarily responsible for the discharge process.

• Responsibilities and related practice interventions: managing symptoms, screening of patients, educating and promoting self‐management, establishing and maintaining relationships with patients and relatives, and engaging patients and relatives in the design and implementation of the plan; internal collaboration with hospital staff.

2.3.1.2. A Qualitative Interview Study

An explorative, qualitative study describing the TCNs' practice related to transitions from hospital to home of older patients with multi‐morbidity and their experiences of their functions and roles (Møller et al. 2022).

Results from the qualitative study provided data on:

• Position: the content and competencies.

• Responsibilities: promotion of continuity and being primarily responsible for the discharge process.

• Responsibilities and related practice interventions: screening of patients, collaboration and coordination of care with internal hospital staff and external municipality staff, collaboration with patients and relatives.

2.3.1.3. An Umbrella Review of Systematic Reviews

An umbrella review describing, appraising and synthesising the combined evidence from systematic reviews according to the content and improvement of patient outcomes of interventions comprising elements from the Transitional Care Model to older people with multi‐morbidity (Berthelsen et al. 2024).

Results from the umbrella review comprised data on:

• Responsibilities: promotion of continuity and being primarily responsible for the discharge process.

• Responsibilities and related practice interventions: screening of patients, educating and promoting self‐management, establishing and maintaining relationships with patients and relatives, and engaging patients and relatives in the design and implementation of the plan; external collaboration with municipality staff; providing service from hospital to home.

2.3.1.4. Organisational Documents

Three organisational documents from a university hospital in a rural Danish region about the responsibilities and practice interventions of TCNs were included to add knowledge of the local policies. The three documents consisted of an introduction programme for newly employed TCNs in the hospital and two guidelines for TCNs' internship in hospital and municipality settings, respectively. The internships were established for the TCNs to gain knowledge and understanding of the discharge process in different settings. The three documents were developed by the first author and 10 TCNs from the year 2021 to 2022.

Data from the introduction programme regarded:

• Responsibilities: continuity, nursing care and patient safety during the discharge process; collaboration with municipality staff.

• Practice interventions: engaging patients and relatives in the design and implementation of the plan, practical tasks during discharge.

Data from the guidelines for internship regarded:

• Practice interventions: holding knowledge about municipality service and documentation and sharing knowledge about TCNs' practice interventions during discharge with the municipality staff.

2.3.2. Extraction of Items for the Questionnaire

The first and last authors conducted the extraction of data from the data materials using Graneheim and Lundman's (2004) four‐step manifest content analysis.

• Initially, the first and last author went through the data materials separately and extracted meaning units, consisting of words or statements that related to the same central meaning on all functions, responsibilities, and best practice interventions for TCNs in the discharge process. The authors separately condensed the meaning units of the data material to smaller codes as descriptions close to the data material.

• Secondly, the first author combined the meaning units and codes from both authors in a combined table to gain an overview of the data. The combined table comprised a total of 166 meaning units and 236 condensed codes.

• Thirdly, the first author grouped the 236 condensed codes into 10 overall categories with 15 sub‐categories based on the distribution of the condensed codes.

• Fourthly, the first author grouped the 15 sub‐categories into smaller units to be more precise about the TCNs' functions, responsibilities and best practice interventions. Since the codes from the two research studies and the umbrella review were in English, they were back‐translated to Danish for the questionnaire. The codes were altered to items capable of being evaluated on a relevance scale through a discussion with the native Danish‐speaking last author.

As the content analysis is a qualitative approach, no inter‐rater reliability was assessed.

2.3.3. Validation of the Final Questionnaire

Two clinical nurse specialists, not included in the expert panel, tested the initial draft of the Danish questionnaire for face validity (Polit and Beck 2018) and clarity of the questions. They had several comments and suggestions for re‐writing the questionnaire items concerning clarity. The Clinical Nurse Specialist also identified several redundant items concerning repetition, which were deleted. The final questionnaire consisted of three main areas concerning the TCNs' position, responsibilities, and practice interventions comprising 11 categories, 31 sub‐categories, and a total of 120 items for the experts to evaluate for relevance (Table 1).

TABLE 1.

The categories in the final questionnaire.

Main areas	Categories	Items (N)
The position	Content	4
The responsibilities	Main responsibility	5
	Co‐responsibilities	15
The practice interventions	Practical tasks	14
	Identification and screening of patients	11
	Collaboration and relations with patient and relatives	14
	Internal collaboration with hospital staff	6
	External collaborations and relations with municipality staff	14
	Holding knowledge about municipalities	19
	Sharing knowledge of TCN position with the municipalities	13
	Follow‐up after discharge	5

2.3.4. Data Collection

Since the aim of the Delphi survey focused on a successful discharge and transition to home, knowledge from both settings was important to develop a comprehensive description of best practice interventions essential for TCNs to perform. An initial information meeting was held with the expert panel in June 2024 to inform them about the Delphi survey procedure and timeframe and to encourage them to participate.

2.3.5. The Delphi Survey

The survey consisted of four contacts with the expert panel: a preliminary introduction e‐mail, two Delphi rounds (McKenna 1994), and a conclusive e‐mail. The Delphi survey took place from August 2024 to November 2024 (Table 2).

TABLE 2.

Timeframe of the Delphi Survey.

Survey contacts	Time points
The preliminary introduction e‐mail	28 August 2024
The first Delphi round	2 September 2024–16 September 2024
The second Delphi round	30 September 2024–14 October 2024
The conclusive e‐mail	4 November 2024

A five‐point Likert scale was used for the expert panel relevance rating ranging from (1) not relevant; (2) somewhat relevant; (3) neither/nor; (4) quite relevant; (5) very relevant. Consensus agreement was determined to be reached when ≥ 75% of the expert panel had rated an item in the questionnaire with high relevance (Likert‐scores 4 and 5). According to Keeney and colleagues (Keeney et al. 2006) no recognised guidelines exist about an appropriate level of consensus; however, a cut‐off score of 75% is described as robust.

2.3.5.1. The Preliminary Introduction E‐Mail

The first contact consisted of an e‐mail, sent to the 54 selected TCNs, consisting of an invitation to participate and information about the Delphi survey aim, procedure, and level of participation as well as the ethical and judicial rights of the experts during and after their participation in the panel.

2.3.5.2. The First Delphi Round

The first Delphi round consisted of an e‐mail to the expert panel containing a link to the online SurveyXact questionnaire. The expert panel was first asked to address their demographic characteristics on: sex, age, years as a graduated nurse, current employment in a hospital or municipality setting, and years in their current position. Secondly, the expert panel was presented with the 120‐item questionnaire and requested to rate the relevance on the five‐point Likert scale of each item on the TCNs position, responsibilities, and best practice interventions, respectively. The expert panel was given 2 weeks to respond to the survey, with a reminder sent 1 week after the initial distribution.

2.3.5.3. The Second Delphi Round

For the second Delphi round, the expert panel received an email containing a link to SurveyXact with the adapted questionnaire based on the items that reached ≥ 75% consensus of relevance after the first Delphi round. The expert panel was asked to rate the relevance of the remaining items on the five‐point Likert scale for a cross‐check (Sinha et al. 2011). The rating from the second Delphi round was considered final.

2.3.5.4. The Conclusive Email

The results of the survey were disseminated to the expert panel through e‐mail along with the final list of the TCNs' position, responsibilities and best practice interventions essential to perform during the discharge process of older people with multi‐morbidity and transition to home.

2.3.6. Data Analysis of Delphi Results

After each Delphi round, consensus was determined by calculating the percentage of participants rating items as ‘quite relevant’ or ‘very relevant’ (scores 4–5). Items reaching ≥ 75% consensus were retained. Descriptive statistics were performed in SPSS. Demographic characteristics of the participants were described using numbers and percentages. The results after the first and second Delphi rounds, respectively, were presented in numbers of excluded and included items. No missing data were detected. The final included items were presented in number of items and their percentage of consensus agreement of relevance.

2.3.7. Ethical Considerations

The TCNs in the expert panel were provided with written information about their level of participation, their ethical rights to refuse to participate, to resign from participation, and their rights to anonymity in the first Delphi round. Their reply to the questionnaire was considered as consent to participate. Data collection for the Delphi study was approved by the Danish Data Protection Agency (jrn.nr. p‐2025‐18237) in the University Hospital of Zealand on 27 January 2025.

3. Results

3.1. Characteristics of the Expert Panel Participants

The expert panel consisted of 54 TCNs from five hospitals (n = 38) and 11 municipalities (n = 16) in a rural Danish region. In the first Delphi round, 40 (74.1%) of the 54 experts replied to the questionnaire within the 14‐day time limit (Table 3).

TABLE 3.

Characteristics of participants for Round 1 (N = 40).

Variables	N (%)
Sex
Female	40 (100%)
Male	—
Other	—
Age
25–34	7 (17.5%)
35–44	11 (27.5%)
45–54	13 (32.5%)
55–64	6 (15%)
≥ 65	3 (7.5%)
Years as graduated nurse
1–10	14 (35%)
11–20	8 (20%)
21–30	10 (25%)
31–40	8 (20%)
Employment setting
Hospital	27 (67.5%)
Municipality	13 (32.5%)
Years of employment in current position
0–2	15 (38.5%)
3–4	9 (22.5%)
5–8	7 (19%)
> 8	9 (23%)

The experts were all females between 26 years and 65 years of age (M = 46). The experts had been educated as nurses between 1 and 38 years ago (M = 20 years). The experts were currently employed in a hospital (n = 27) or in a municipality setting (n = 13) and had been in the same position as TCNs for 1 year to over 10 years.

3.2. The First Delphi Round

In the 120‐item questionnaire, consensus agreement of ≥ 75% relevance (4–5 Likert) was found in 60 of the 120 items. The 60 items agreed as relevant by the expert panel were in the three main areas of the TCNs' position, responsibilities and practice interventions (Table 4).

TABLE 4.

Results after first and second Delphi round.

Main area	Categories	Sub‐categories	Number of items (N)	First Delphi round (excluded/included) (N)	Second Delphi round (excluded/included) (N)
The position	Content	Structure	2	(1/1)	(1/0)
		Qualifications	2	(1/1)	(0/1)
The responsibilities	Main responsibility	Coordinating the discharge	5	(0/5)	(0/5)
	Co‐responsibilities	Securing continuity in the discharge process	3	(0/3)	(0/3)
		Nursing care in the discharge	4	(3/1)	(0/1)
		Patient safety during discharge	4	(1/3)	(0/3)
		Collaboration during the discharge	4	(0/4)	(0/4)
The practice interventions	Practical tasks	Discharge planning start at admission	4	(1/3)	(0/3)
		Practical, medical, and nursing considerations	3	(0/3)	(0/3)
		Documentation during the discharge process	7	(1/6)	(0/6)
	Identification and screening of patients	Identify patients at risk for deterioration	5	(2/3)	(0/3)
		Screening patients' health status	6	(6/0)	(0/0)
	Collaboration and relations with patient and relatives	Establish and maintain relations with patients and relatives	3	(1/2)	(2/0)
		Involving patients and relatives in planning interventions for nursing care	5	(0/5)	(0/5)
		Teaching and guiding patients and relatives	6	(6/0)	(0/0)
	Internal collaboration with hospital staff	Collaboration and coordination	4	(0/4)	(0/4)
		Acknowledging differences in knowledge between staff members	2	(0/2)	(0/2)
	External collaborations and relations with municipality staff	Collaboration	6	(3/3)	(0/3)
		Communication	4	(0/4)	(1/3)
		Relations	4	(1/3)	(0/3)
	Holding knowledge about municipalities	Knowledge about municipality service and care	2	(0/2)	(0/2)
		Knowledge about municipality distribution of care	2	(1/1)	(0/1)
		Knowledge about municipality documentation systems	2	(2/0)	(0/0)
		Knowledge about receiving patients in home	4	(4/0)	(0/0)
		Knowledge about receiving patients in nursing home or rehabilitation centre	4	(4/0)	(0/0)
		Knowledge about planning of further treatment after discharge	5	(5/0)	(0/0)
	Sharing knowledge of TCN position with the municipalities	Knowledge about internal hospital interventions for discharge	8	(7/1)	(0/1)
		Knowledge about the hospital documentation system	5	(5/0)	(0/0)
	Follow‐up after discharge	Telephone follow‐up	3	(3/0)	(0/0)
		Home visits	1	(1/0)	(0/0)
		Telephone follow‐up and home visits	1	(1/0)	(0/0)
		Included items		60	56

3.2.1. The Position of the Transitional Care Nurses

One item of four was rated as highly relevant concerning the sub‐category of Qualifications (one of two items) stating ‘The TCN must have been trained for a minimum of two years and have experience in clinical nursing’ (Table 4).

3.2.2. The Responsibilities of the Transitional Care Nurses

One full category was included comprising the main responsibilities of coordinating the discharge (all five items). To full sub‐categories were also included covering the co‐responsibilities of the TCN of Securing continuity in the discharge process (all three items) and Collaboration during the discharge (all four items). One item was agreed to be highly relevant by 100% of the expert panel members. This concerned having main responsibility of ‘A safe discharge of patients with complex needs’ in the sub‐category of coordinating the discharge (Table 4).

3.2.3. The Practice Interventions of the Transitional Care Nurses

One full category was included comprising internal collaboration with hospital staff containing the two sub‐categories of collaboration and coordination (all four items) and acknowledging differences in knowledge between staff members (both items). Four full sub‐categories were also included covering practical, medical and nursing considerations (all 3 items), involving patients and relatives in planning interventions for nursing care (all 5 items), knowledge about municipality service and care (all 2 items), and communication (all 4 items).

Six items in the practice interventions area were agreed to be highly relevant by 100% of the expert panel members. The practice intervention items were ‘To use the Nursing Care Plan in communicating with the municipality’ in the sub‐category of documentation during the discharge process, and ‘To identify patients with complex problems who have special needs during discharge’, and ‘To identify patients who are at risk of deterioration during the transition from hospital to municipality’ in the sub‐category of identify patients at risk for deterioration. Three of the six highly relevant items were within the category of external collaborations and relations with municipality staff concerning ‘To hold discharge meetings (planning meetings, extended coordination) between the sectors, patient and relatives when relevant’ (sub‐category collaboration), ‘To ensure that communication is both IT‐based and dialogue‐based to ensure the best discharge for the patient’ (sub‐category communication), and ‘To contribute to create a mutual cross‐sectoral respect through participation in the Regional Network for Transitional Care Nurses’ (sub‐category relations). The final item was in the category of holding knowledge about municipalities concerning ‘How the Health Agreement and the Toolbox (Regional guidelines for discharge) are relevant to the discharge’ (Table 4).

3.2.4. Exclusion After the First Delphi Round

The first Delphi round excluded a total of 60 items. No full categories or full sub‐categories were excluded completely in the main areas of the position or the responsibilities of the TCNs however, six single items were excluded. There were two items agreed as not relevant by the expert panel concerning the position of the TCNs: ‘How the position should be a full‐time employment’ (sub‐category of structure) and ‘How the position should require nursing experience from primary care and hospital care’ (sub‐category of qualifications).

Four items were agreed as not relevant by the expert panel concerning the responsibilities of the TCNs: to own co‐responsibility of ‘Planning and prioritising nursing care in relation to the discharge process’, ‘Initiating nursing assessments for discharge on the day of admission’, and ‘Evaluating nursing assessments throughout the patient's admission that have an impact on the care and treatment the patient needs at discharge’ (sub‐category of nursing care in the discharge) as well as to own co‐responsibility of ‘Avoiding worsening of the patient's symptoms and illnesses during the discharge process’ (sub‐category of patient safety during discharge).

In the main area of the TCNs' practice interventions, 54 items were agreed as not relevant in the consensus of the expert panel. One full category was rated as not relevant by the expert panel comprising Follow‐up after discharge with the sub‐categories: telephone follow‐up (all 3 items), home visits (the one item) and telephone follow‐up and home visits (the one item). Seven full sub‐categories were excluded from the consensus agreement of the expert panel. Four of the seven sub‐categories were in the category of holding knowledge about municipalities comprising knowledge about municipality documentation systems (all 2 items), knowledge about receiving patients at home (all 4 items), knowledge about receiving patients in nursing home or rehabilitation centre (all 4 items) and knowledge about planning of further treatment after discharge (all five items). The three additional sub‐categories excluded were: screening patients' health status (all 6 items), teaching and guiding patients and relatives (all 6 items), and knowledge about the hospital documentation system (all five items).

3.3. Second Delphi Round

In the second Delphi round, the remaining 60 items were sent to the 54 members of the expert panel as a SurveyXact link by e‐mail. The response rate in the second Delphi round was 31 of the 54 experts (57.4%). Four items were evaluated as not relevant by 75% or more of the experts and were therefore excluded (Table 4).

Three of the final four items excluded in the second round resulted in the exclusion of two sub‐categories: ‘How the position should be specialised and administrative’ (the last item in the sub‐category structure in the category of content), and ‘To contact the patients' relatives’ and ‘To establish and maintain a trusting relationship with the patients and their relatives’ (the last two items in the sub‐category of establish and maintain relations with patients and relatives in the category of collaboration and relations with patient and relatives). The fourth item excluded in the second round was ‘Coordination care between the hospital and primary care’ (sub‐category of communication) (Table 4).

After the second and final round, 56 items were included covering the expert panels' consensus opinion on the position, responsibilities, and practice interventions essential for hospital‐employed TCNs to perform a successful discharge process of older people with multi‐morbidity and transition to home (Table 5).

TABLE 5.

Final included items (N = 56).

Main areas	Categories, sub‐categories and included items	Final items included (% relevance)
The position	Content
	Qualifications	1 of 4
	The TCN must have been trained for a minimum of 2 years and have experience in clinical nursing	(80%)
The responsibilities	Main responsibilities
	Coordinating the discharge	5 of 5
	To be the primary coordinator of the discharge process from the hospital	86%
	To be the primary coordinator of the discharge process across the sectors	76%
	To coordinate the discharge process on the basis of professional assessments	90%
	A safe discharge of all patients in collaboration with interdisciplinary partners	82%
	A safe discharge of patients with complex needs	100%
	Co‐responsibilities
	Securing continuity in the discharge process	3 of 3
	To promote continuity by ensuring contact between staff at the hospital and in the municipality	100%
	To have a focus on reconciliation of expectations between the patient, relatives and health professionals in planning future care and treatment	93%
	To focus on documentation and dissemination of agreements regarding the discharge process	96%
	Nursing care in the discharge	1 of 4
	To distribute the plan for nursing care to municipal bodies when the patient is discharged	89%
	Patient safety during discharge	3 of 4
	To secure the overall quality of the discharge process	87%
	To plan discharges to avoid unintended incidents	96%
	To plan discharges with a focus on avoiding readmissions	100%
	Collaboration during the discharge	4 of 4
	To cooperate with the patient and relatives during the discharge process	93%
	To focus on the main objectives relevant for the individual patient in the discharge process	86%
	To gain a good interprofessional collaboration in the discharge process	96%
	To gain a good cross‐sector cooperation in the discharge process	96%
Practice interventions	Practical tasks
	Discharge planning start at admission	3 of 4
	To create an overview of tasks and their coordination at the start of admission	82%
	To coordinate the discharge early in the hospitalisation process	89%
	To participate in planning the day of discharge	85%
	Practical tasks during admission	3 of 3
	Ensure that the practical considerations are part of planning the discharge process	93%
	Ensure that the medical considerations are part of planning the discharge process	85%
	Ensure that the nursing considerations are part of planning the discharge process	97%
	Documentation during the discharge process	6 of 7
	To prepare and send a thorough completion of the Nursing Care Plan	96%
	To use the Nursing Care Plan in communicating with the municipality	100%
	To document the discharge planning in the patient record	85%
	To prepare and send a thorough completion of the Discharge Report	85%
	To use the Discharge Report in communicating with the municipality	81%
	To ensure that the medical registration is corrected for discharge	82%
	Identification and screening of patients
	Identify patients at risk for deterioration	3 of 5
	To identify patients with complex problems who have special needs during discharge	93%
	To identify the patient's needs in the discharge process	89%
	To identify patients who are at risk of deterioration during the transition from hospital to municipality	86%
	Collaboration and relations with patient and relatives
	Involving patients and relatives in planning interventions for nursing care	5 of 5
	To have a supportive and continuous dialogue with the patient about their needs, wishes and goals after discharge	89%
	To involve and integrate the patient's needs, wishes and goals in planning care after discharge	85%
	To talk to the patient about his home situation	96%
	To promote patient and relatives' participation in decision‐making and co‐determination regarding care and treatment based on their preferences, values and goals	85%
	To promote collaboration with the patient and relatives in relation to various aspects of life at home, admission and discharge planning	89%
	Internal collaboration with hospital staff
	Collaboration and coordination	4 of 4
	To participate in an active collaboration with colleagues within the hospital to coordinate the patient's care and treatment after discharge	97%
	To contact other health professional in the hospital when another expert knowledge in relation to discharge is necessary	89%
	To participate in jointly planned conversations with colleagues, for example, goal conversations, sitting room, extended coordination/planning meetings, whiteboard meetings	81%
	To be part of the internal coordination of the time of discharge	81%
	Acknowledging differences in knowledge between staff members	2 of 2
	That the special knowledge of different health professional is necessary to plan a good discharge process	96%
	That different health professional have different responsibilities in the discharge process	96%
	External collaborations and relations with municipality staff
	Collaboration	3 of 6
	To cooperate with the municipality's TCN regarding the patient's discharge process	100%
	To make contact with relevant staff in the municipality regarding the discharge process	92%
	To hold discharge meetings (planning meetings, extended coordination) between the sectors, patient and relatives when relevant	93%
	Communication	3 of 4
	To promote communication and connections between hospital and municipality	92%
	To ensure that the hospital's care and treatment initiatives are communicated to the municipality	97%
	To ensure that communication is both IT‐based and dialogue‐based to ensure the best discharge for the patient	97%
	Relations	3 of 4
	To strengthen relations between TCN in the hospital and in the municipality through participation in the Regional Network for Transitional Care Nurses	93%
	To strengthen the ability to solve problems with the municipality TCNs through participation in the Regional Network for Transitional Care Nurses	92%
	To contribute to create a mutual cross‐sectoral respect through participation in the Regional Network for Transitional Care Nurses	93%
	Holding knowledge about municipalities
	Knowledge about municipality service and care	2 of 2
	The municipalities' offers and opportunities for practical and personal help	82%
	How the Health Agreement and the Toolbox (Regional guidelines for discharge) are relevant to the discharge	87%
	Knowledge about municipality distribution of care	1 of 2
	The work function and authority of the visitors	81%
	Sharing knowledge of function with the municipalities
	Knowledge about internal hospital interventions for discharge	1 of 8
	That occasionally late discharges may occur, as the discharge itself can be affected by the doctor's work and operations	78%

4. Discussion

This two‐round Delphi survey determined expert clinicians' consensus opinion on items concerning the position, responsibilities, and practice interventions relevant for hospital‐employed TCNs to perform a successful discharge process of older people with multi‐morbidity and transition to home. The high response rates of 74.1% after the first round and 57.4% after the second round show the commitment to the study aim of the TCNs in the expert panel. The results of the Delphi survey show how the expert panel agreed on the high relevance of 56 key items out of 120 items presented.

The main and co‐responsibilities of the TCNs were agreed by the experts to be highly relevant for structuring the discharge process for the patients. The most important responsibilities were considered by the experts to be the sub‐categories of coordinating the discharge; securing continuity in the discharge process; and collaboration during the discharge (with internal and external staff and patients), where all initial items were finally included. A specific responsibility rated as highly relevant was securing patient safety during discharge, which was found by the experts' 100% agreement on the relevance of the items ‘A safe discharge of patients with complex needs’ (in the main responsibility sub‐category of Coordinating the discharge) and ‘To plan discharges with a focus on avoiding readmissions’ (in the co‐responsibility sub‐category of patient safety during discharge). The focus on the TCN's responsibilities during the discharge process has also been highlighted in the Transitional Care Model (Naylor et al. 2018). The model was developed to improve outcomes of at‐risk older adults throughout acute care transitions from hospital to home and has been demonstrated to enhance older adults' care experiences and improve their quality of life (Naylor et al. 2018) and reduce healthcare costs (Hirschman et al. 2015) and readmissions (Morkisch et al. 2020). The Transitional Care Model share similarities with the findings of relevant responsibilities in this Delphi study as the primary core nursing components are promoting continuity, coordinating care, and collaborating with patients, caregivers and teams (Naylor et al. 2018).

The results of the Delphi survey showed how the experts agreed on the relevance of more administrative nursing tasks of coordination, continuity, and collaboration; but it also found a low consensus on items about establishing patient relationships. This was found by the experts' exclusion of three of four items in the sub‐category nursing care in the discharge, the sub‐category screening patients health status, and the category collaboration and relations with patients and relatives, containing the sub‐categories of establish and maintain relations with patients and relatives, and teaching and guiding patients and relatives. This could raise questions about whether the Danish implementation of the TCN role may be too narrowly focused on system‐level coordination rather than direct patient contact related to transitional care. Hirschman et al. (2015) have emphasised the essential components of establishing and maintaining trusting relationships with patients and their caregivers and educating patients in managing their symptoms and risks in their study on the Transitional Care Model, components which were excluded by the experts in the Delphi survey as not relevant. The lack of the TCNs' direct relations with the patients and their relatives could have implications concerning the TCN's abilities to identify the patients' needs during and after discharge. The framework of Fundamentals of Care (Kitson 2018) is explicit on the core element of a trusting relationship as a key to distinguish patients unspoken needs. Instead, the TCNs rely on information about the patients from their nursing colleagues who perform the direct care and contact with the patients. However, the experts in the Delphi survey do agree on the high relevance of involving patients and relatives in planning interventions for nursing care, which was also deemed relevant in the Transitional Care Model (Naylor et al. 2018; Hirschman et al. 2015). An ethnographic observational study of discharge planning also found that communication with patients and relatives was considered best practice recommendations (Gane et al. 2022).

With the experts' high agreement on the relevance of system‐level coordination in the TCN's responsibilities and practice interventions, it is fair to discuss whether another healthcare professional or administrative personnel other than nurses could be responsible for the coordination, continuity, and collaboration in the patient's transition from hospital to home. Studies indicate that transitional care is comprehensively about coordination and securing continuity in the discharge process (Morkisch et al. 2020; Naylor et al. 2018) and that direct nursing care is seldom reported as important for the transitional discharge process, for readmissions or for reducing adverse events. Hayajneh et al. (2020) propose that a discharge planner can be a social worker, attending physician, or case manager because the discharge process is too time‐consuming and complex for nurses. However, the studies included in their systematic review all identified nurses as the cornerstone of discharge planning (Hayajneh et al. 2020).

In contrast, research on transitional care points at the necessity of having a lead nurse in charge of the discharge process for comprehensive planning and coordination of the transition, collaboration with other healthcare professionals and securing continuity in care (Naylor et al. 2018; Berthelsen et al. 2024; Hirschman et al. 2015). Naylor et al. (2018) describe how clinical nurses support TCNs with knowledge from direct patient care and detect early changes in the patients' health status and that other healthcare professionals support the discharge planning. Naylor et al. (2018) further emphasise, that the Transitional Care Model is a care management model led by a TCN in a team‐based collaboration. The considerations of transition as a team‐based effort were supported by the results of the Delphi survey that found all items in the category of internal collaboration with hospital staff included as highly relevant (sub‐categories of collaboration and coordination and Acknowledging differences in knowledge between staff members). The results also showed 100% agreement of relevance in the item ‘To cooperate with the municipality's TCN regarding the patient's discharge process’ (category of external collaborations and relations with municipality staff: sub‐category collaboration) and in the item ‘To promote continuity by ensuring contact between staff at the hospital and in the municipality’ (category of co‐responsibility: sub‐category securing continuity in the discharge process). There is no consensus on the best model of discharge planning (Gane et al. 2022) but a team‐based collaboration with knowledge from all healthcare professionals involved during the patients' admission (Ibrahim et al. 2022; Zanetoni et al. 2023) accompanied by a lead TCN responsible for coordination, continuity and collaboration (Naylor et al. 2018; Berthelsen et al. 2024; Hirschman et al. 2015) could provide a safe transition of patients from hospital to home.

4.1. Methodological Considerations

The participants in the expert panel were TCNs from hospitals and municipalities in a rural Danish region. Since the study aimed to determine expert clinicians' consensus opinions on the position, responsibilities and practice interventions relevant for hospital‐employed TCNs, the results could be skewed by including opinions from municipality‐employed TCNs. However, the municipality‐employed TCNs have extensive collaboration with the hospital‐employed TCNs and thereby hold knowledge on what is essential for them to perform a successful discharge process of people with multi‐morbidity.

A strength was determining consensus agreement at ≥ 75%. The literature on Delphi surveys proposes an agreement range from 51% to 70% to decide consensus (Hayajneh et al. 2020) however, no recognised guidelines exist about an appropriate level of consensus (Keeney et al. 2006; Shariff 2015). Keeney et al. (2006) however describe a cut‐off score of 75% as robust.

A limitation to consider is the drop‐in response rate between the first (74.1%) and second (57.4%) Delphi rounds, where 9 experts did not participate in the second round. While such attrition is common in Delphi studies (Keeney et al. 2006), it could have influenced the final exclusion decisions, as each response carried more weight in reaching the 75% consensus threshold with fewer participants. The characteristics of non‐respondents in the second round were not analysed, and it remains unclear whether their non‐participation might have impacted the final consensus.

A consideration concerning the TCN's level of experience was valued by the authors as important for the results. The TCN's agreed that being trained for a minimum of 2 years and having experience in clinical nursing had high relevance for the position. However, 35% of RNs answering the survey had 1–10 years of experience as graduate nurses, and 38.5% were in their current TCN role for 0–2 years, which could influence results.

There were some areas not included in the Delphi survey that the research group were made aware of by the TCNs afterwards as important for their role in the discharge of older patients. One area included teaching registered nurses about the important documentation elements in the discharge process such as composing a care plan. Another important area was the digital competencies of the TCNs to master the digital communication with the municipalities and to conduct online discharge meetings with the patients GP and home care providers.

5. Conclusions

This two‐round Delphi study provides valuable insights into how experts conceptualise the TCN role within the Danish healthcare context. The findings highlight that coordination and continuity of care processes are central to this specialised nursing role, with particular emphasis on system‐level organisation and cross‐sectoral collaboration. While the role focuses primarily on discharge planning and coordination, it operates within a broader team‐based framework that involves multiple healthcare professionals across hospital and municipality settings. The expert consensus suggests that TCNs contribute to safe transitions through their comprehensive understanding of both hospital and community care systems, their ability to coordinate complex care processes, and their skill in facilitating communication between healthcare providers, patients and families.

5.1. Further Research

The findings from the Delphi study provide an important foundation for further development of the TCNs' role, particularly in defining professional competencies and organisational structures that support effective care transitions. Through further research, we will conduct an implementation study focusing on operationalising the 56 items addressing TCNs' position, responsibilities, and practice interventions essential for older patients' transition in clinical practice. The implementation study will be designed according to the Consolidated Framework for Implementation Research (CFIR) to promote implementation theory development and to gain timely understanding of barriers and facilitators to practice transformation (Damschroder et al. 2009). We will furthermore perform an estimation of the potential costs of the implementation considering training of TCNs.

Future research should evaluate the impact of this coordinating role on patient outcomes, including readmission rates and adverse events, while exploring how it complements other healthcare professionals' contributions to transitional care.

Author Contributions

C.B.: conceptualisation; data curation; formal analysis; investigation; project administration; methodology; validation; writing – original draft; and writing – review and editing. C.M.: conceptualisation; formal analysis; validation; writing – review and editing. B.L.: conceptualisation; data curation; formal analysis; investigation; validation; writing – review and editing.

Ethics Statement

The Delphi study was approved by the Danish Data protection agency (jrn no. p‐2025‐18,237).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: jan70168‐sup‐0001‐DataS1.docx.

Berthelsen, C. , Mabire C., and Lerbæk B.. 2026. “Position, Responsibilities and Practice Interventions Relevant for Danish Transitional Care Nurses to Perform During Discharge of Older People: Delphi Survey.” Journal of Advanced Nursing 82, no. 5: 5178–5193. 10.1111/jan.70168.

Data Availability Statement

The data that support the findings of this study are not available as the participant did not disclose accept of data sharing.