Nursing roles and tasks in transitional care for young people with chronic conditions: An integrative review

BACKGROUND: Nurses play a pivotal role in supporting adolescents with somatic chronic conditions during transition to adult care, yet their specific contributions within multidisciplinary teams remain insufficiently defined and are often overlooked. OBJECTIVE: To synthesize the nursing roles and tasks during the transition of adolescents with chronic conditions from pediatric to adult hospital services. METHODS: An integrative literature review was conducted using Embase, Medline, Web of Science, CINAHL, Cochrane, and Google Scholar. English-language studies published between 2000 and mid-2025 were included. Data were analyzed thematically in Atlas.Ti® and integrated with the "On Your Own Feet" framework. RESULTS: Of 5726 identified papers, 54 met inclusion criteria. Twenty-four studies reported original research; 13 were descriptive studies; and 17 were reviews, 10 of which reflected single-expert opinion. Eight nursing roles in transitional care were identified: Service Coordinator, Liaison to Community, Innovator, Clinician, Researcher, Educator, Coach, and Advocate. These roles encompassed coordinating care, supporting self-management, educating adolescents and families, facilitating communication, aligning pediatric and adult services, and contributing to innovation and evaluation. Coordination and self-management support were more frequently described than psychosocial or parental support. Despite the central role of nurses, few studies evaluated nursing interventions, and no evidence was found regarding the effectiveness of nurse involvement in transitional care. CONCLUSIONS: Nurses fulfil diverse and essential roles in transitional care that extend transfer coordination to adolescent empowerment, family support, and alignment between pediatric and adult services. Future research should evaluate the effectiveness and impact of nursing roles to strengthen evidence-based transitional care.