3 Transition of care stomatic patients: Transition of care for stomatic

Abstract

Objective: to describe a multidimensional educational intervention carried out with nurses, about the transition of care for ostomized patients in the Health Care Network, in southern Brazil. Method: convergent care research carried out with nurses from the Health Care Network in a municipality in the state of Rio Grande do Sul, Brazil. Data collected through participant observation and an educational workshop, based on care for the ostomy patient. Thematic analysis technique. Results: main weaknesses: difficulty in referencing and counter-referencing, lack of communication and gaps in knowledge. The activities resulted in propositions constructed dialogically to overcome weaknesses: organization of the schedule of updates; creation of referral/counter-referral protocols, patient transfer by telephone, appointment scheduling at the referral unit; use of digital applications for communication. Conclusions: the strategy resulted in active participation and reflection on professional practices and allowed the identification of weaknesses in the care transition process and possibilities for improvement.