Most older adults with dementia live at home, they primarily receive care provided by family members and friends. Given the decline in memory and other cognitive functions, there to be higher rates of touch points with the health system for those living with dementia. Evidence has shown that these care transitions mark critical changes in the lives of older people, including significant and far-reaching changes to family caregivers. Therefore, it is imperative that complex social processes enacted by persons with dementia and their family caregivers in response to care transitions be more thoroughly explained. This study took place in Canada between 2019 and 2021 and adopted a constructivist grounded theory design. Twenty-five people participated in 20 interviews: 4 people living with dementia and 21 caregivers. We report on six concepts grounded in the data that are linked to a core process engaged in by the participants throughout the care transition journey and beyond: Seeing the day-to-day situation. This study contributes theoretically to the care transition literature by making explicit not only the visible work done by patient-caregiver days during the care transition journey, but it has also illuminated the ongoing processes engaged in by caregivers who are navigating the health and social care systems with their family member living with dementia. During the care transition, and beyond, the caregiver is forced to take over and connect the dots. Even though the caring experience is fraught with traumatic and very challenging situations, for many caregivers, they rise above and can reconcile their suffering with a desire to help their family member and others who may be going through similar experiences. This theory provides a foundation on which to develop theory-driven interventions that focus on support the patient-caregiver dyad during care transitions.

大多数患有痴呆症的老年人住在家里，他们主要接受家人和朋友的照顾。鉴于记忆力和其他认知功能的下降，痴呆症患者与卫生系统的接触点比例更高。有证据表明，这些护理转变标志着老年人生活的重大变化，包括家庭护理人员发生的重大而深远的变化。因此，必须更彻底地解释痴呆症患者及其家庭照顾者为应对照顾转变而制定的复杂社会过程。本研究于 2019 年至 2021 年在加拿大进行，采用建构主义扎根理论设计。25 人参加了 20 次访谈：4 名痴呆症患者和 21 名护理人员。我们报告了六个基于数据的概念，这些概念与参与者在整个护理过渡过程及以后所参与的核心过程相关联：查看日常情况。这项研究在理论上为护理过渡文献做出了贡献，不仅明确了在护理过渡过程中患者-护理人员天数所做的可见工作，而且还阐明了正在导航健康和社会护理系统的护理人员正在进行的过程他们的家人患有痴呆症。在护理过渡期间及以后，护理人员被迫接管并连接各个点。尽管护理经历充满了创伤和非常具有挑战性的情况，但对于许多护理人员来说，他们超越自我，能够将痛苦与帮助家人和其他可能经历类似经历的人的愿望相协调。该理论为开发理论驱动的干预措施提供了基础，这些干预措施侧重于在护理过渡期间支持患者-护理人员二元组。