RNQualitativeThe Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres2026

Nurses' and Patients' Perspectives on Care Coordination Across Health Care and Social Services Sectors: A Qualitative Study.

Marlène Karam, Maud-Christine Chouinard, Meghry Kevork and 2 others

PMID 41212728

WHAT IT FOUND

Nurse coordinators and older patients or caregivers described care coordination as helped by trusted continuity, shared information, and clear roles, and hindered by territorial boundaries, unclear roles, and discharge pressures.

Key findings

01Patients and caregivers valued continuity with the same care coordinator, and changing coordinators was described as frustrating.

02Nurse care coordinators, colleagues, supervisors, and informal caregivers described unclear role boundaries and responsibilities as a barrier to coordination.

03Participants described unclear contacts outside the local territory and pressure for early discharge as barriers to coordination.

STILL TO COME

How it was doneWhat they foundWhat it means for RNs

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What it does not show

This was a qualitative study of perceptions in one Quebec integrated health and social services centre, so it does not test whether care coordination improves health outcomes. The sample was small and purposive: 10 nurse care coordinators and 9 patients or informal caregivers, and the authors note the informal caregiver sample size may be a limitation. Patients were aged 65 to 86 and selected for physical vulnerability and frequent emergency department visits or hospitalizations, so findings may not apply to younger patients or those with less complex needs. Interviews with coordinators and patients or caregivers were done in separate periods, August to December 2022 and February to June 2024, so experiences may have changed over time. Some themes concern organizational and workforce issues, such as role clarity, territorial boundaries, and discharge pressure, which may limit direct application to individual clinical care.

Declared interests

The study was funded by the Social Sciences and Humanities Research Council of Canada, grant number 892-2021-3020. The authors declared no potential conflicts of interest. The study was conducted in partnership with the Nursing Care Directorate of the integrated health and social services centre.

The easy way to misread this

Do not read these themes as evidence that nurse care coordination improves patient outcomes. The study interviewed 10 nurse care coordinators and 9 patients or informal caregivers and reported their perceptions, not a tested intervention.

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