Navigating in healthcare systems – A qualitative study on Socially Marginalized Patients’ Experiences of the Hospital Transition and Support by Social Nurses

Background: Socially marginalized patients face many challenges related to their health condition and often have several contacts with healthcare and social service workers. The Danish social nursing initiative, whose nurses have experience and knowledge about marginalization, aims to support socially marginalized patients during hospital admission and through hospital transitions. However, limited knowledge about the hospital transitions of patients supported by a social nurse has been found.<br/>Objectives: The objectives were to explore (1) the perspectives of socially marginalized patients on the transition from hospital to home and (2) how these patients experience the importance of social nursing on patient trajectories after hospital discharge.<br/>Methods: A qualitative study with a phenomenological and hermeneutic approach was performed at a large hospital in southern Denmark. Adult patients having contact with a social nurse during hospital admission were purposely sampled. Data were collected from January 2023 to March 2023. Initial patient interviews were conducted with sixteen patients during hospital admission, and thirteen of the patients participated in a second interview 7–22 days after discharge. Systematic text condensation was applied for the analysis, and Nvivo 12 supported data storage and coding. The analysis was synthesized by the research group in a workshop. Patient representatives were involved in qualifying the themes.<br/>Ethical approval: This study is registered with the Danish Data Protection Agency (22/47509). Informed consent was given by the participants.<br/>Results: Five themes were identified in the analysis: (1) Being prepared for the transition (2) The transition from hospital to everyday life, (3) A need for individual support, (4) It is a matter of timing, and (5) The importance of coordinating support before, during, and after the transition. The participants experienced major challenges in their transitions from the hospital generally related to their interactions with many different social and healthcare services. While the social nurses supported the patients in facilitating care during hospital admission and after discharge, the participants identified transitional care gaps related to multidisciplinary cooperation and standardized care options. <br/>Conclusions: This study identifies challenges related to the hospital transition of socially marginalized patients, which indicates a gap in healthcare services.