Toward Nurses' Transformative Agency in Transitional Care for Older Adults: A Change-Laboratory Intervention.

Mobilization of nurses' agency across healthcare sectors is needed to counter challenges associated with older adults' transitions between hospital and primary care. Based on Cultural Historical Activity theory and the Change Laboratory method, we developed a learning intervention with 16 nurses. The aim was to foster the nurses' transformative agency to improve care. Video-recording of nine learning sessions were transcribed and analyzed. Results demonstrated that shared transformative agency exhibited as an emergent phenomenon crossing sectoral boundaries as a prerequisite for change in transitional care. The nurses progressed from acting as individuals criticizing the current conditions to collectively forming a vision around a transitional care model. This was nurtured through the nurses' negotiations which included a recognition of sharing similar challenges deriving from the healthcare organization and related financial restrictions, and conflicting healthcare and nursing ideals across healthcare sectors. The evolution of transformative agency was grounded in a professional nursing identity.

Introduction

Nurses and other healthcare practitioners need to be involved in the development of transitional care for older adults (Buch et al., 2018). Although a considerable number of interventions have been performed to improve transitional care for older adults, a number of challenges seem to persist (Aase et al., 2017). These challenges include breakdowns in care, lack of trust between patients, family and healthcare professionals, lack of commitment on the part of the patients and next of kin, and poor communication between healthcare professionals, all of which jeopardizes patient safety (Naylor et al., 2018).

Nurses act as key coordinators of transitional care (Swan et al., 2019; Weeks et al., 2018). However, it is less clear how they position their roles and responsibilities as contributors to the development of practice. This might be related to nurses’ sharp distinction between the task of taking care of patients and the task of contributing to developing transitional care (Høgsgaard & Dissertation, 2017) or to the fact that responsibility for development of new approaches to care is assigned to researchers and managers rather than nurses (Coleman & Boult, 2003; Naylor et al., 1999; Virkkunen, 2013). However, development led by researchers and managers may encounter barriers among practitioners. A study showed that practitioners perceived the implementation of an evidence-based transitional care model as a threat to their professional roles (Naylor et al., 2009). Thus, the development of transitional care may go hand in hand with the formation of agency among nurses.

The notion of transformative agency signifies that a group collectively “breaks away from a given frame of action and takes the initiative to transform it” (Virkkunen, 2006, p. 43). This differs from traditional notions of agency where individuals’ personal characteristics and skills rather than collective agency are emphasized in promoting development of new approaches (Buchanan et al., 2016; McCormack et al., 2013). Transformative agency can be achieved through formative interventions that differ from other types of interventions by the emphasis on the cultural and historical aspect of work activities. In a formative intervention participants investigate how their work practice has developed over time to identify dilemmas and contradictions causing the actual problems in order to reconceptualize the object of the whole work activity (Virkkunen, 2013). Transformative agency may serve to develop work practices, for example, when participants collectively envision new possibilities and take action to make changes to improve practice. Transformative agency evolves over time when participants debate and gradually develop a vision of a transformation of practice (Engeström, 2006). Studies have found formative interventions to be useful in the development of transformative agency in homecare, teaching within higher education, military settings, and the logistics industry (Englund & Price, 2018; Haapasaari et al., 2014; Moffitt, 2019; Nummijoki, 2020; Sannino, 2010).

Research is needed to establish how nurses may be collectively committed to contribute to the development of transitional care. The aim of this study was to explore how nurses exhibit transformative agency.

Methods

This study was designed as a formative learning intervention exploring participants’ collective learning in transitional care between secondary care and primary care. We used the Change Laboratory method which is based on Cultural Historical Activity Theory and on the theory of expansive learning, used in other contexts to promote workplace innovation and learning (Engeström, 2015). The Change Laboratory method includes a cycle of learning actions encompassing six steps: (1) questioning existing practice, (2) analyzing disturbances by focusing on conflicts and contradictions encountered in practice, (3) envisioning and examining new possibilities, (4) implementing, (5) reflecting, and (6) consolidating the transformation of practice (Engeström, 2015; Virkkunen, 2013). Characteristically for the Change Laboratory method, the learning intervention was structured as a series of sessions focusing on the first four steps of the expansive learning cycle where the participants analyzed and envisioned a transformation of transitional care for older adults.

We previously investigated how participants enabled a reconceptualization of their transitional care practice (Bøje et al., 2021). The present study focuses on participants’ transformative agency. As we will argue in this article, the study meets the second of the two aims of the Change Laboratory method that is to “build up the practitioners” collaborative and transformative agency and motivation based on a new understanding of the idea of the activity and a new perspective of its future development”(Virkkunen, 2013, pp 10).

Setting and Participants

The setting included a Danish acute hospital with a basic catchment area of 225,000 inhabitants and a primary care department in a municipality with 47,000 inhabitants located within the hospital’s catchment area. Participants were recruited from a medical department including a geriatric and an administrative unit, an acute care unit (hospital), an administrative unit, a homecare unit, an acute care unit and a short-term unit (municipality). The first author, who is an experienced nurse educator, facilitated the learning intervention. In addition to the co-authors, three research assistants were involved; two students, and one nurse who had experience with transitional care from the hospital.

Participants eligible for the learning intervention were hospital and municipality health professionals engaged in nurses’ transitional care on a daily basis. Sixteen potential participants were purposefully selected and invited by the first author or a head of unit.

The Change-Laboratory Intervention

The Change Laboratory intervention was conducted over 6 months from May to October 2019. Organized as nine sessions each with a duration of 2 hours, the Change Laboratory intervention was held in a meeting room at either the hospital or in the municipality. We invited all the participants to partake in eight sessions. One session, the third, was held as two separate sessions for participants from the two health sectors. Sessions were video recorded by two research assistants. The co-authors took turns being passive observers.

To foster transformative agency, we first confronted the participants with a problematic situation in the form of a patient case which had been developed at an earlier stage of the project (Bøje et al., 2021). Then, we showed activity system models that served as a representation of practice (Engeström, 2015) to stimulate the participants’ identification of problematic situations in practice (Sannino, 2015). We used the actions of questioning, analyzing and modeling distributed across learning sessions with actions, problems, tools and tasks as shown below in Table 1.

Table 1.

Overview of Learning Intervention.

Learning session	Learning actions	Mirror data	Stimulating tools	Tasks to be performed between sessions	Participants present*
1.	To question current practice	A patient case	Activity system model	N/A	5 M4 H
2.	To question current practice and identify challenges	A patient case	Activity system model	Find documents representing the formation of transitional care practice	5 M5 H
3a.	To analyze the formation of challenges in transitional care	Minutes from meetings, official healthcare agreements and published reports	A historical timeline	Consider what is the intention with collaboration	8 M
3b.	To analyze the formation of challenges in transitional care	Minutes from meetings, official healthcare agreements and published debates of the organization of healthcare	A historical timeline		3 H
4.	To analyze current and former practice and identify systemic causes to challenges and need for development	Suggestions from facilitator based on statements from participants in former sessions	Activity system modelsPresentation of different models of collaboration	Consider systemic causes to challenges in transitional care practice	7 M3 H
5.	To analyze current and former practice and identify systemic causes to challenges and need for development	Suggestion from facilitator based on statements from participants in former sessions	Activity system modelsPresentation of different integrated care models	Consider systemic causes to challenges in transitional care practice	3 M4 H
6.	To develop a future transitional care model	Debates, and statements from participants in former sessions	Presentation of levels of patient involvementPresentations of different paradigms in public management	Make suggestions of a new transitional care model	3 M5 H
7.	To develop a future transitional care model	Debates, and statements from participants in former sessions	Questions to prompt concretization of solutions and plan for further process	Concretize solutions	4 M5 H
8.	To develop a future transitional care model	A suggested vision for a new transitional care model provided by the facilitator	Questions to prompt concretisation of solutions and plan for further development process	Plan the future development process	5 M5 H

Participants from municipality (M)/Hospital (H).

In accordance with the literature, the facilitator aimed to balance two concerns: on the one hand provoking and challenging the participants and on the other hand being sensitive to differences in their need for internal processing (Virkkunen, 2013). Furthermore, the facilitator stimulated a formative learning process by remaining open to the directions in which the participants’ discussions evolved and by following the detailed planning made for the sessions (Virkkunen, 2013).

The first author and two research assistants transcribed the video recordings from the sessions verbatim. Subsequently, we imported the transcriptions to qualitative data management software (Nvivo12 Plus), which was used to organize and analyze the data (Jackson & Bazeley, 2019).

Analysis

The analysis of how nurses’ transformative agency evolved in this Change-Laboratory intervention was guided by the analytical framework developed by Cultural Historical Activity Theory scholars where agency is expressed through discourse and action (Haapasaari et al., 2014). In this Change-Laboratory intervention, discourse and action were maintained in the transcribed data from the learnings sessions. First, we identified speaking turns - the smallest unit of analysis—in the data. Next, using identification criteria containing an expression of agency, we coded the speaking turns according to six types of expressions of transformative agency (see Table 2). Then, we quantified the number of expressions within each type of transformative agency to determine which types of transformative agency were most frequently represented in the data.

Table 2.

Six Types of Expressions of Transformative Agency and Identification Criteria.

Type of expression	Identification criteria
Resisting	Resisting or opposing to change, to new suggestions or initiatives from management, co-workers or facilitator.
Criticizing	Change oriented critique of the current activity and organization aiming at identifying problem in current ways of working.
Explicating	Explicating new possibilities or potentials in the current activity. Relating to past positive experience or former well-tried practices.
Envisioning	Future oriented- Envisioning new patterns or models in the activity. Future oriented suggestions or presentations of a new way of working.
Committing to action	Committing to taking concrete new actions to change the activity in the form of speech acts tied to time and place.
Taking action	Reporting having taken consequential actions to change the activity in between or after the laboratory sessions.

Source. Table adapted from Haapasaari et al. (2014).

Subsequently, based on contextual situation of the speaking turns in the transcribed data, we merged all speaking turns categorized within any of the six agencies into discussion topics. Discussion topics were enacted by the participants as a reaction to the stimuli provided during the learning intervention. Therefore, we considered the discussion topics as contributing aspects nourishing the evolution of the participants’ agency across learning sessions (Haapasaari et al., 2014). Finally, we integrated the findings from the analysis of speaking turns, types of expressions and discussion topics into an explanation of the evolution of the participants’ transformative agency across the Change-Laboratory sessions.

Ethical Considerations

All participants signed informed consent forms. In accordance with the ethical guidelines for medical research involving human subjects, the study was guided by the principles of autonomy, beneficence, non-maleficence, and justice (World Medical Association, 2018). According to the Danish Healthcare Act, this study was exempted from ethical registration as it did not involve the study of human biological material, nor did it contain person-identifiable data or form part of a clinical trial (Komitéloven & Komitéloven, 2020). The study was registered with the Danish Data Protection Agency (R. No. 2012-58-006, Sequential No. 211) and approved in pursuance of National Data Protection Legislation (Databeskyttelsen, 2018).

Findings

All 16 invited healthcare professionals agreed to participate. Nine were from the hospital and seven were from the municipality. They were employed as frontline nurses, heads of unit, research and development nurses and local authority officers (see Table 3). To ensure anonymity, participants were categorized as hospital participants (HP) or municipality participants (MP) and referred to as HP 1-7 and MP 1-9.

Table 3.

Participant Characteristics.

Affiliation	Number of participants	Department	Role in Organization	Age	Years of experience in current role	Sex	Number of sessions attended
Hospital	7	Medical Department, Emergency department, Administration	Clinical Nurse, Head of Unit, Research and Development Nurse, Consultancy	Between27 and 60Median = 41 years	Between 0,5 and 14Median = 3 years	Women	Between 1 and 8Median = 5 sessions
Municipality	9	Primary Care, Acute Care, Nursing Triage, Social Services, Triage Unit	Clinical Nurse, Head of Unit, Research and Development Nurse, Local Authorithy Officer	Between28 and 62Median = 54 years	Between5 and 18Median = 5 years	Women	Between 1 and 8Median = 4 sessions

Note. Data from nine sessions produced 19 hours of video recordings that were transcribed into 426 pages of text (177,402 words).

Transformative Agencies Most Frequently Represented During the Change-Laboratory Sessions

We identified 3,319 speaking turns and 566 expressions of transformative agency. We found that transformative agency evolved from mainly criticizing to envisioning assessed by the number of expressions observed across the learning sessions (Figure 1).

Figure 1.

Distribution of expressions of transformative agency across the learning sessions.

(Sessions x-axis—expressions of transformative agency y-axis).

While criticizing was the predominant type of transformative agency in the beginning of the sessions, envisioning became a widely dominant type of agency toward the end of the sessions. Furthermore, the agencies of criticizing and envisioning accounted for a rather large number of expressions of transformative agency. Expressions of resistance mainly occurred from the middle of the sessions and onward, whereas explicating expressions occurred throughout the sessions, in particular in session six. Fewest expressions occurred within the categories of committing to specific actions and taking consequential action and mostly so toward the end of the learning sessions.

Discussion Topics That Nourished Participants’ Transformative Agency

We identified five discussion topics as aspects contributing to the evolution of transformative agency: (1) Recognizing that nurses share similar challenges across healthcare sectors, (2) Recognizing the need to change nurses’ priorities in transitional care; (3) Defending frontline nurses as key coordinators of care; (4) Recognizing differences in the perception of patient involvement; (5) Negotiating meaningful values grounded in nursing ideals. In Table 4 the discussion topics and examples show as subcategories within the identified transformative agencies.

Table 4.

Transformative Agencies and Discussion Topics Including Examples.

Type of transformative agency	Subcategories based on topic	Examples of expressions of transformative agency
Resisting (n = 126)	1. The intervention method (n = 15)2. Fellow participants’ suggestions or perceptions of practice (n = 79) including:• Labeling a new transitional care model (n = 22)• Perceptions of patient involvement (n = 26)• Suggestions of new tools or functions (n = 22)• Perceptions of change possibilities (n = 9)3. Managers’ lacking insight in practice (n = 5)4. Political introduced visions and concepts (n = 11)	Ad. 1. “It made a big impression on me both to see how enthusiastic everyone seemed, but also how frustrated everyone seemed. I do not share this perception of practice. I wonder how we would have felt if the focus was on what goes well instead.” [HP6]Ad. 4. “These value- creating words that all organizations have been obliged to implement, they are completely fluffy and unmanageable in a normal work life.” [MP9].
Criticizing (n = 204)	1. The conditions to provide transitional care (n = 90)2. The organizational division of social services and healthcare (n = 34)3. Counterparts’ incomplete use of transitional care documents (n = 8)4. Nursing practice (n = 36)5. Collaboration tools (n = 36)	Ad 1. “When financial restrictions and transitions of tasks from hospital to primary care are on the agenda it unconsciously becomes a them against us culture and puts pressure on the collaboration.” [HP3]Ad 2. “The balance is difficult, because you are the ones confronted with a next of kin who wishes to get her mother placed in a nursing facility. Moreover, you have no authority to make such decisions. They think that you can make magic.” [MP9]Ad 5. “You might have a minor concern about the patient, but ICT tools are not suitable for that kind of concerns. This type of information exchange has vanished.” [HP6]
Explicating (n = 54)	1. Improvement of nurses’ collaboration (n = 10)2. Improvement of the conditions (n = 23)3. Improvement of patient information (n = 21)	Ad 2. “When the management asks us to follow the healthcare agreements and value-based visions I think we should take them up on that and do it. Then, live with being balled out for not following the procedures costing the organization money and eventually make them realize that you most probably saved money and made the patient happy.” [MP7]
Envisioning (n = 175)	1. Labeling a new transitional care model (n = 52)2. Nursing practice (n = 40)3. The further development process (n = 25)4. Collaboration tools (n = 58)	Ad 1. “I think it is scary to see how the patients have vanished from those drawings (pointing toward the completed activity system models). I think that the word co-creation when attached with values attributed to nursing would emphasize the inclusion of patients.” [MP7].Ad 4. “We need an easily managed app where the patient can master their own data and be coordinators of their own patient pathway. It needs to help them to manage their medicine as well. If we empower the patients to manage themselves. I bet we can avoid some readmissions” [HP4]

Within the category of criticizing, the discussion topic that triggered most expressions of transformative agency was the nurses’ work conditions to provide transitional care. The discussion topics that provided most expressions of transformative agency within the envisioning category were patient involvement and the nurses’ role in transitional care.

Recognizing That Nurses Share Similar Challenges Across Healthcare Sectors

The perception that nurses shared challenges was derived from the participants’ critique of the conditions to provide transitional care. The debate of the conditions included a critique of the organization and specialization of healthcare and a perception that financial restrictions were an obstacle preventing nurses from achieving an overview of the patient and thus affecting the collaboration and their relationships with the patient. However, the debates concerning the conditions fostered a recognition of similarities between the encountered challenges. This is illustrated in the following conversation that involved primary care nurses from the municipality [MP6 and MP7] and a hospital-based nurse [HP5]:

MP6: It is difficult to get an overview and this is what I strive to do when I assess the patients. One thing might be an infection, but we also try to figure out whether the patient gets something to eat or drink, for instance. However, when I hear your talk about the patient—these things are missing. And this is reflected in the information you provide to us. Another thing is that the patient is treated at the hospital for one issue. Then he is discharged and then may readmitted to be treated for another issue. Moreover, the patient most probably does not have a clue about what is going on. But this has nothing to do with the nurses. It is caused by the organization of healthcare. No one looks across the patient pathway.”

HP 5: It is like an auto mechanic workshop. The leg is broken, so that’s what you fix.

MP6: Yes, and then they are discharged. In addition, the patients who are admitted are the most vulnerable and socio-economically challenged ones. They most likely do not get a new appointment at the general practitioner despite your recommendations. This overview is missing.

MP7: We have the same challenges. We have high expectations to ourselves and each other concerning our ability to maintain an overview of the patient situation. You must have an overview of the whole patient situation in no time concerning a patient who might stay admitted for only 3 days. And we might see the patient for 4 minutes to give an injection and then we are expected to have a complete overview. We are somehow on a mission impossible and this frustration we have in common.

The above conversation initially concerned a primary care nurse’s critique of hospital nurses’ lacking overview. However, the conversation developed into a critique of the specialization and organization of healthcare as obstacles for nurses aiming to provide an overview. In this way it became a mitigating distraction from the initial critique of hospital nurses. Finally, the conversation showed how common ground was established among the participants in the perception that they share similar challenges across healthcare sectors.

Recognizing the Need to Change Nurses’ Priorities in Transitional Care

The nurses’ recognition of the need to change their priorities in transitional care derived from a small number of expressions of critique directed toward nursing practice. These included critique of nurses’ predominant focus on the patients’ physical conditions and on meeting managerial demands, which impeded relational care and patient involvement.

In the process of identifying challenges in transitional care, one hospital participant offered a new perspective on the participants’ predominant focus that the conditions lay at the root of challenges encountered. One municipality participant emphasized time restriction as an obstacle to providing relational care:

MP5: This might sound a bit provocative, but when you make people work like we do in a clockwork tyranny, the sole focus is on solving the task you were told to do. Because it is on the list that you have to give an injection. You then go through the door with blinders on. I am not saying that everyone does this, but it is really difficult to provide considerate and caring practice under these conditions.

A hospital participant seconded the focus on the impeding conditions by emphasizing nurses’ different foci for patient care according to specialization:

HP3: I think that we have different goals for patient care. As an acute hospital, we must focus on treatment of the acute condition because that is the key task. This means that we do not have the resources to build the overview you need. This creates a dilemma between what we wish to do and what is physically possible. You have to ensure the stability of patients’ everyday life, and we have to receive the patients when things get out of hand. We have different backgrounds for performing a shared task. This creates challenges.

Another hospital participant acknowledged her fellow participants’ standpoints and simultaneously offered another possibility in her reply:

HP5: I very much agree with you. However, I think that it is thought provoking how little we focus on establishing a relation with the patients and, in particular, with their next of kin. We often exclude the relatives. We must be able to provide more care. We must be able to do something to improve the relation with our patients and their next of kin.

The above conversation shows that the last participant offered an alternative to the predominant focus on the impeding conditions by directing the critique toward nursing practice and simultaneously envisioning the possibilities for changing nurses’ priorities in nursing practice.

Defending Frontline Nurses as Key Coordinators of Care

The defence for frontline nurses as key coordinators of care emerged from suggestions about how to solve the challenges deriving from the conditions under which the nurses needed to provide transitional care. This defence was expressed as resistance from two hospital participants:

“It is kind of devastating that the discharge of patients has become such a complex task that we have to reallocate resources from frontline nursing to be able to afford a discharge coordinator” (HN3). This triggered resistance from another hospital participant who replied “I really have to oppose to that. I know the patient best, and I should coordinate patient care” (HN7).

The above excerpt shows a defence of frontline nurses based on a clear perception of nurses’ role and responsibilities in transitional care.

Recognizing Differences in the Perception of Patient Involvement

The participants’ discussion on the current level of patient involvement in transitional care produced recognition of differences in the perception of patient involvement. This may be attributed to transformative agency in the form of resistance toward co-participants’ perceptions. The discussion was linked to the critique of nurses’ lacking emphasis on relational care and patient involvement. The resistance arose from a question posed by the facilitator about the current level of patient involvement and revealed perceptions ranging from perceiving the patients as involved or questioning the patients’ ability to be involved, to the perception that patients are excluded in nurses’ transitional care collaboration.

Negotiating Meaningful Values Grounded in Nursing Ideals

The participants negotiated a way to label a transitional care model. The transitional care model served as an indicator of change for nurses’ future transitional care practice. A grounding in nursing ideals served as a way to establish common ground and to foster resonance among the nurses. The negotiation that the nurses engaged in in order to label a transitional care model manifested itself as expressions of resistance.

The negotiation included an attempt to introduce a meaningful labeling that resonated with nurses as opposition to politically introduced concepts perceived as being disconnected from practice. This was reflected in a perceived incongruence between regional and local political visions emphasizing that transitional care collaboration was based on patients’ conditions and the reality, where patients were rarely involved. “We have a vision claiming that patients should be involved in decisions about care and that care should be based on patients’ needs. That nearly makes me puke, sorry, but these are empty words” (MP6).

The participant expressed how concepts and guides about transitional care could be perceived as being disconnected from practice despite being rooted in good intentions. The two quotes below reflect grounding in nursing ideals and an emphasis on finding words that resonate with nurses. The debate aiming to establish a suitable label for the transitional care model included suggestions to emphasize notions of nursing ideals and patient involvement, for example, care, compassion, equality in dialog and responsibility. A municipality participant argued, “I think it is scary to see how the patients have vanished from our collaboration. I think that the word co-creation when linked to values attributed to nursing would emphasize the inclusion of patients” (MP7). The quote shows a suggestion from the participant justified by reference to nursing ideals. Furthermore, the negotiation included the participants’ emphasis on establishing meaningfulness in connection with the suggested words. The facilitator suggested the word integration which one hospital participant replied to. “This shows how you interpret words differently, because for me integration is related to the integration of refugees. I think interaction is more. . .well, it is a difficult word. We have to find a word which is meaningful to us all” (HP6). The quote illustrates the dynamics between facilitator and participant. This manifested in the participants’ emphasis on the use of meaningful words as a rejection of the suggestion proposed by the facilitator.

The nurses’ recognition that they shared similar challenges across healthcare sectors derived from criticizing the conditions under which they need to provide transitional care. This subject provided most expressions of transformative agency (See Table 4). The critique produced competing suggestions of causes to the challenges in transitional care, including recognition of the need for nurses to shift their focus from the patients’ physical conditions and meeting managerial demands in transitional care practice to emphasizing relational care and patient involvement. This insight was developed through criticizing and envisioning. Simultaneously, the critique produced suggestions to improve conditions, including the implementation of a transitional care coordinator. This insight was produced by explicating. This provoked a defence for frontline nurses to fulfill their role as coordinators of care. This insight was produced owing to resistance. The recognition of the need for nurses to prioritize differently triggered participants’ endeavors to emphasize relational care and patient involvement in a transitional care model. This led to the recognition that different perceptions existed of the current level of patient involvement. Finally, the participants found guidance in nursing ideals in their negotiations regarding how to label a transitional care model.

Discussion

Our analysis of how nurses’ transformative agency is expressed in this Change Laboratory intervention revealed that transformative agency evolved in an emergent manner from individual critique to a shared vision across healthcare sectors and organizational boundaries. The evolution of transformative agency was nourished by five contributing aspects deriving from discussions and dynamics between the nurses. These aspects included: (1) Recognizing that similar challenges were shared across healthcare sectors (2) Recognizing the need to change nurses’ priorities in transitional care; (3) Defending frontline nurses as key coordinators of care; (4) Recognizing differences in the perception of patient involvement; (5) Negotiating meaningful values grounded in nursing ideals.

Most importantly, we found that transformative agency evolved from participants’ individual critique toward a shared vision for transitional care through the means of a transitional care model. The finding of a shared agency differs from the traditional understanding that change agency should be attributed to individuals (McCormack et al., 2013). Grounded in the individual account of agency, Buchanan et al. (2016) found that the division of individual agency across healthcare settings and inclusion of healthcare managers from different healthcare professions is beneficial for the development of complex interorganizational healthcare practices and secures sustainability. Our finding that the evolution of transformative agency occurred within a group of nurses representing different professional roles and healthcare sectors differs from the findings of Buchanan et al. by expanding agency even further to encompass practitioner nurses.

Another important finding was that transformative agency evolved from individuals’ critique to becoming a shared vision in the form of a transitional care model, serving as an artifact to create a new shared motive for nurses to practice transitional care. Similarly, Nummijoki (2020) found that for agency to become shared between homecare workers and their clients requires a shared motive which can be enacted by an artifact. According to Virkkunen (2006), shared agency distributed within a group of individuals involved in a shared practice is a beneficial precondition for achieving sustainability in the transformation of practice. This finding is important for the development of transitional care. Considering the current challenges, we argue that a need exists for drawing on nurses’ knowledge and experiences in order to renew transitional care. This is supported by Buch et al. (2018) who found that integrative care models are likely to fail without agency from practitioners and a grounding in local practices.

Another overall finding important for the development in transitional care was that the Change Laboratory served as a space for nurses to discuss and identify challenges in transitional care. The occurrence of transformative agency types during the learning sessions indicates that the nurses are change-oriented and focus on what needs to be changed rather than resist change. This shows in the majority of quotes criticizing and in the fact that expressions of critique predominantly occurred in the beginning of the learning sessions and in the fact that resistance mainly occurred in the middle and toward the end of the learning sessions. This observation represents a slight deviation from the expected order which, according to Cultural Historical Activity Theory, is initial resistance and criticizing which is gradually replaced by committing and taking action (Haapasaari et al., 2014). Our limited findings of the categories of committing and taking action have to be seen in connection with the planned learning actions in the intervention, which did not include the implementation phase where consequential actions are typically executed (Virkkunen, 2013).

The predominance of criticizing was also found in change laboratories interventions in higher education and in the parcel logistics industry and is an indication of a practice in need for change (Englund & Price, 2018; Haapasaari et al., 2014). We found that the nurses’ critique mainly concerned the conditions under which they needed to provide transitional care. This is in line with current debates and research arguing that the organization of healthcare is an obstacle to coherent patient pathways across healthcare services (Aase et al., 2017; Buch et al., 2018). We also found that the critique nourished the nurses’ transformative agency as a motivation for development because they recognized that they shared similar challenges across organizational sectors. The emergence of a shared motive to develop practice has significance for the development of transitional care because disparities in perceptions of values, culture and patient goals and disconnections between healthcare sectors have been found to flourish among nurses (Hesselink et al., 2013).

Another finding of significance for the development of transitional care was that several of the discussions and dynamics between nurses that contributed to the evolution of transformative agency were grounded in a professional nursing identity. Professional nursing identity includes identification with a community of practice and with the values and ethics of a profession including the knowledge and ability to fill the professional role as a nurse acquired through education and a personal identification as a professional of an identified professional group (Fitzgerald, 2020). First, the grounding in a professional nursing identity is clear from the critique that nurses surrender to managerial demands concerning the costs of relational care and patient confidence. This reflects an inherent understanding of nurses’ responsibility toward emphasizing relational care. Next, it is clear from the defence of frontline nurses as coordinators of care as this reflects an inherent understanding of nurses as the more competent group to coordinate care qua their direct contact with the patient. Finally, it is clear from the use of nursing ideals in the negotiation of labeling for a transitional care model reflecting an inherent understanding of professional values and ethics. In Change Laboratory interventions, the participants are confronted with problematic situations in their practice and are then provided with stimuli in the form of conceptual tools to identify and resolve practice challenges. However, the stimuli can also be invented by the participants themselves in the form of meaningful signs (Sannino & Engeström, 2017). We argue that grounding in a professional nursing identity served as an implicit artifact that contributed to transformative agency by providing meaningfulness to the nurses’ endeavors toward developing a transitional care model. The grounding in nurses’ professional identity is in line with a more general and growing awareness that nurses’ care is foundational to all caring activities, healthcare systems and institutions (Kitson et al., 2019).

Strengths and Limitations

Transformation of practice requires long-term commitment, and often several Change Laboratory interventions are needed (Engeström et al., 2014). Furthermore, evolution of transformative agency is a prolonged learning process (Haapasaari et al., 2014). Thus, one limitation to this study is that the identification of an emerging shared transformative agency is unlikely to lead to pervasive transformations of transitional care. Furthermore, Sannino and Engeström (2017) argue that thorough analysis and identification of how transformative agency exhibits may provide knowledge about how agency can be purposefully cultivated. Seen in this light, we argue that our findings of an emerging shared transformative agency and the contributing aspects form the necessary platform for a transformation of nurses’ transitional care for older adults. Furthermore, we provide transferable knowledge of how nurses’ transformative agency may be cultivated.

Another limitation in this study was the inconsistency in participation in the learning sessions. This impeded our attempts to give equal voices to the participants and resulted in time spent on keeping everyone up to date with the process.

A strength of this study is the demonstration of how the theoretical foundation in Cultural Historical Activity Theory and the use of the Change Laboratory method stimulate a division of agency in the development of transitional care encompassing nurse practitioners. This possibly diminishes practitioners’ resistance toward implementation of new innovation as encountered by Naylor et al. (2009).

Conclusion

Nurses’ emerging transformative agency showed in an evolution from individual nurses criticizing the current conditions within which they need to provide transitional care toward a shared vision of a transitional care model. This development was nurtured by the nurses’ recognition that they shared similar challenges across healthcare sectors. Furthermore, grounding in a professional nursing identity served as an artifact of meaning contributing to the evolution of transformative agency. This was reflected in negotiations of the nurses’ role and responsibilities, patients’ role and nursing ideals.

This finding is important for the development of transitional care and is of interest to clinical nurses, managers and educators interested in developing practice-based nursing knowledge. The study shows how to engage nurses in negotiating different roles and a reconceptualization of transitional care across healthcare organizations in the development of their practice. For nurses to engage and take agency to developing practice, it is necessary to provide possibilities for and acceptance of critique, resistance and debates of practice-based experience of relevance for nurses. Furthermore, we suggest that a distributed mandate and responsibility allowing the development of the intervention to encompass nurses from different levels of the involved organizations may facilitate the implementation and the sustainability of the changes achieved in practice.

The impact of the participants’ organizational roles and power hierarchy are beyond the scope of this article. However, these themes provide interesting perspectives for future research into aspects related to the evolution of shared transformative agency.