title: Cultural diversity between hospital and community nurses: implications for continuity of care.
abstract: BACKGROUND
  Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains.
  
  
  CONCLUSIONS
  In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be 'ready to be discharged'.
  
  
  CONCLUSIONS
  We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.
authors.affiliation: Institute of Health and Society, Department of Nursing and Health Sciences, University of Oslo, Norway. ragnhild.helleso@medisin.uio.no <ragnhild.helleso@medisin.uio.no>
authors.forename: Ragnhild
authors.initials: R
authors.lastname: Hellesø
authors.forename: May Solveig
authors.initials: MS
authors.lastname: Fagermoen