Transitional Care Support for Patients with Heart Failure: A Qualitative Study of Nursing Practices by Ward, Discharge Planning, and Visiting Nurses.

AIM: This study explores the nursing practices of transitional care support for patients with heart failure performed by three different groups of nurses: 1) ward, 2) discharge planning, and 3) visiting nurses. DESIGN: We conducted a qualitative, content analysis. METHODS: Twelve ward nurses, four discharge planning nurses, and five visiting nurses were purposively sampled. Data were collected through semi-structured interviews and analyzed using content analysis. RESULTS: Ward nurses implemented four practices, including "Encourage patients to improve to prevent re-exacerbations" and "Share information with the home care team." Discharge planning nurses implemented four practices, including "Communicate with the home care team to ensure the continued management of heart failure." Visiting nurses implemented three practices, including "Make efforts to obtain test results and, based on physical signs, symptoms, and the pathological condition, detect signs of heart failure exacerbation." CONCLUSION: In transitional care support for patients with heart failure, the three different groups of nurses (ward, discharge planning, and visiting) must multilaterally share information on patients' pathological conditions, the progression of test results, and physical reactions during activities, while continuing to provide support for lifestyle adjustments.