Involvement of the Home Care Team in Supporting the Self-care of Late-stage Older Patients with Heart Failure as Perceived by Visiting Nurses

Abstract

Purpose: To clarify the involvement of home care teams in supporting self-care in older patients with heart failure, as perceived by visiting nurses.

Method: Semi-structured interviews were conducted at a visiting nursing station in Prefecture A with 13 nurses who had experienced cases of late-stage older patients with heart failure who had not been readmitted for more than six months after discharge.

Results: As a result of the qualitative descriptive analysis, nine categories were generated from 31 subcategories regarding the involvement of the home care team in supporting the self-care of late-stage older patients with heart failure.

Discussion: To prevent older patients with heart failure from being re-admitted to the hospital, it is important for them to have a purpose and role in their home life and want to remain at home. We believe that the keys to long-term home life are "providing relaxed management tailored to the individual patient" and "supporting home life in any way possible while respecting the patient's wishes." We also believe that it is important for everyone not to overlook signs of worsening heart failure by "getting instructions on adding diuretics based on ‘body weight,' which can be determined from everyday measurement" and "paying attention to anything different from usual so it leads to early medical examination." Furthermore, we believe that it is important to provide family guidance that considers adherence so that families can support self-care while understanding the need for heart failure management.