Abstract
This study aimed to clarify how discharge planning, ward, and visiting nurses collaborate to provide coordinated care during the period of transition from hospital care to home care. We conducted semi-structured interviews with 2 groups, each consisting of a discharge planning nurse, a ward nurse, and a visiting nurse who were involved in transition support for the same patient （total, 2 patients） and qualitatively analyzed the results. The following 6 categories were extracted:“discharge planning, ward, and visiting nurses provide transition support focused on the desires of the patient and family members”, “discharge planning and ward nurses cooperate to promote transition support”, “ward nurses provide support while imagining the patient’s home living condition and confirm with visiting nurses”, “discharge planning nurses connect the ward and visiting nurses”, “discharge planning and visiting nurses trust each other to take over the handling of patient issues and nursing care”, and “visiting nurses provide feedback on patient home life to the discharge planning and ward nurses”. Coordinated care provided by the three parties during the transition period included not only recognizing each nurses’s particular position and role, focused on the desires of the patient and family members, but also acting in consideration of each nurse’s position and role, and then providing feedback on maintaining the patient’s lifestyle at home after the transition.
