Purpose：This study aimed to clarify the content of post-discharge transitional care for older patients who were discharged from acute hospitals to their homes.

Method：We conducted semi-structured interviews with eleven Discharge Planning Nurses involved in transitional care at acute hospitals.

Results：We categorized the post-discharge transitional care for patients into two types of actions: assessment and intervention. Next, we identified twenty-one subcategories and seven major categories by analyzing the content of post-discharge transitional care for patients. The seven major categories included “assessment of post-discharge care,” “encouragement for patients to have a vision of their future care based on the reality of post-discharge care,” and “establishment and maintenance of good relationships among patients, families, and care teams.”

Conclusion：Discharge Planning Nurses provided ongoing support and encouragement to various stakeholders in their continued care for the diverse post-discharge needs of older patients. This study will contribute to improving the quality of transitional care by professionals, and it is necessary to consider standardizing the content of post-discharge transitional care and the verification of its effectiveness in the future.

Purpose：We aimed to identify the frustrations caused by ethical dilemmas among visiting nurses who provide end-of-life care to people aged 75 or older （late-stage elderly）.

Method：Data were collected through semi-structured interviews with six visiting nurses who had over 5 years of experience in their field and then analyzed qualitatively and inductively.

Results：The following frustrations among visiting nurses were found: although they wish to practice end-of-life care that respect the preferences of late-stage elderly patients, “the preferences of the patients themselves are not respected,” “patients are not provided with nursing care that meets their needs” （including end-of-life nursing care for patients and their families）, and although multidisciplinary collaboration is necessary, “patients are not provided with end-of-life support by multidisciplinary health professionals.”

Conclusion：Three categories of frustrations experienced by visiting nurses in end-of-life care for the late-stage elderly were extracted. To avoid or alleviate these frustrations, visiting nurses may need to learn ethical principles and　approaches for resolving ethical issues, and to study cases by applying these ethical principles. Strengthening of community-based support systems for end-of-life care may also be necessary.

Purpose：This study aims to identify the relationship between the internal systems of visiting nurse stations (hereinafter referred to as "station") and staff retention to develop a system that helps stations improve their operations.

Methods：A questionnaire survey of 288 station administrators in the six prefectures of the Tohoku region, who have worked for at least five years at the station and supervised at least four nursing staff (including part-time staff), was conducted.

Results：The mean of average station staff retention rate derived from the 115 valid responses was 57.4 (±27.1)%. Considering the administrator’s discretionary power over the budget, an all-staff meeting at least once a day, a new hire training programme, a step-by-step education programme, and the assignment of a certified nurse (CN) or certified nurse specialist (CNS), the retention rate was significantly higher in all cases in stations with internal systems than in stations without such systems.

Conclusion：The study suggested that strengthening the administrators’ management skills, building relationships within the organisation, improving educational programmes and the systems that ensure the quality of care may increase the staff retention rate.

Purpose： This study clarifies the difficulties of home healthcare for patients wearing an implantable ventricular assist device (IVAD) and the support needs for specialized facilities by homecare nurses.

Method：This study targeted 43 homecare nurses who worked at 15 homecare nursing agencies who had experiences of introducing the care from heart transplantation facilities for patients wearing an IVAD. A self-administered questionnaire was used to collect information about difficulties in care and the needs for specialized facilities from 24 homecare nurses obtained the consensus.

Results：20 homecare nurses who experienced nursing for the patients were analyzed. The homecare nurses had no image of the wearer's condition before discharge, and even after discharge, it was difficult to judge the urgency of connecting to a specialized facilities for changes in the condition and life events. Therefore, it was necessary for specialized facilities to continuously share information and develop a consulting environment.

Conclusion：In response to the unknown anxieties and difficulties in homecare nurses, specialized facilities can demonstrate advanced knowledge provision and monitoring functions from an early stage before discharge. It was suggested that this support would enable safe and secure home care.

The purpose of this study was to describe the function of homecare nursing agencies established by the university. Five agencies were selected after considering the characteristics of the region and the university. Semi-structured interviews were conducted with seven persons who were deeply involved in the establishment as well as conversant with its background, activities, and issues. Their inputs were transcribed into transcripts, wherein the function was described. While integrating semantic content, attention was paid to the differences and similarities in the contents. Utilization of the educational and research functions combined with the advanced medical and nursing practice skills that formed part of the university’s activity characteristics, contributed to strengthening support for home-based transition and expanding the alliance function between agencies. The agencies could this function as providing education and human resources along with specialized services through cooperation with nearby agencies.