obvious special needs, so that no readmission to the ICU would occur. This one time, they cooperated between our clinics among the discharge, but you got the feeling that it was only because that they didn’t want to have the patient return again . . . (ICU nurse) If the patient and the relatives met with the ward nurses before the discharge, and with the ICU nurses after the discharge, for a follow up, this created an intertwining. However, this sort of collaborating was more often expressed as a wish from the nurses than was actually performed. Both ICU and ward nurses said that providing informa- tion about the ward was important for a successful transition. This information varied greatly depend- ing on which nurse was in charge of the actual patient because of the lack of intertwining and missing routines in ICU transitional care. However, the ICU nurses sometimes felt it difficult to provide the ward’s information to the patients and the relatives. They did not always have actual informa- tion concerning the routines, etc. to give to the patient. Intertwining with a liaison nurse was also de- scribed as a successful way of handling transitional care. The liaison nurse was someone in charge of and responsible for organizing transitional care, creating meetings with different team members and planning for the follow-up of possible future needs for the patients. This meeting provides the liaison nurse the opportunity to inform the ward nurses of the transfer, giving them time to prepare for the needs of taking over the patient. Collaboration with the departments was also performed when the ward nurses consulted the ICU nurses to learn new supplements/procedures. . . . We had this patient with a unfamiliar tracheot- omy that made many nurses anxious . . . The ICU nurses were here a lot before the discharge and demonstrated how to proceed the suction . . . We also knew that the ICU nurses always were available for support. (Ward nurse) Wishing for routines that facilitate patient centeredness. The nurses expressed a desire for routines that facilitated patient-centeredness and wanted strate- gies to use with the team members and the clinics involved. They wanted routines that facilitated patient-centeredness and wished that the caregivers would take responsibility for the individual, instead of only considering the advantages for their own unit. The nurses were aware that the planning had to Struggle with a gap between ICUs and general wards 187 consider the individual patient’s needs, as well as general routines in transitional care, so intertwining could be accomplished. If there were strategies that described how to handle the whole ICU transitional care process, the planning would be simplified. If the nurses had routines to rely on, they could provide safer and better transitions for patients and their relatives. Set strategies would also simplify matters for the staff involved in care when another physician was put in charge. You have to have a strategy, that’s what it is all about. Every ICU should have clarity in what routines to use when moving an intensive care patient to the ward. That is where to start! (ICU nurse) The ICU nurses expressed ambiguity concerning what authority and responsibility they had in plan- ning the process; they relied heavily on the physi- cians’ decisions. However, they felt that they often possessed a great deal of influence in the process. The ward nurses felt absolutely no influence in the ICU transitional care process, and their own role in it was undefined. They expressed a wish not only to see to their patients’ care but see the whole chain in the journey of the patients’ transitional care and to take responsibility for the care after or before their own department. Striving for control When the patient was about to be transferred, the control of the patient was transferred from the ICU nurses to the ward nurses. The ICU nurses and the ward nurses strove for control, wanted access to necessary tools, relied on questioning their compe- tence, and sought assurance of the patients’ ability to accept the altered level of care. Wanting access to the necessary tools. The ICU nurses felt that one of their tools for providing good care was connected to the opportunity to plan the transfer properly. They wanted to prepare both the ward and the patient very well for the transition so that care could be continued properly. If the patient needed some unusual supplement at the ward, early planning was important so that the ward nurses did not miss things when the patient arrived. The relay-race baton has to be given away in a proper way, so that the ward nurse gets the opportunity to continue the care for the patient. (ICU nurse)