Introduction: We aimed to clarify the characteristics of the activities of nurses who provide end-of-life care to users of small-sized multifunctional in-home care services (SMICS) and consider effective end-of-life care for elderly persons who use SMICS.Methods: Semi-structured interviews were conducted with 16 nurses who belonged to SMICSs, and the results were analyzed qualitatively and inductively.Results: The nurses provided four core categories of support: "support so that the elderly person and their family can spend a better end-of-life period together while maintaining their everyday lifestyle," "support so that the family and care staff can deal with the elderly person's dying process," "support so that the elderly person or their family can clarify where and how they want to spend their end-of-life and fulfillment of their wishes," and "provision of medical care suitable for the wishes of the elderly person or their family and disease conditions." Conclusion: The results indicated that nurses supported the elderly and their families by clarifying the care they desire and to support the elderly person, their family, and those who assist them in daily living. In addition, nurses should help not only toward maintenance of daily living but also adapt the medical system so that the elderly person can spend their end-of-life period in a familiar place.

Objective: To improve the discharge planning ability of ward nurses, we carried out case conferences for discharged patients involving both ward nurses and visiting nurses, and assessed their effects.Methods: We compared the discharge planning ability of ward nurses with and without experience in home visits before discharge. The study involved 74 nurses from eight wards in three hospitals. We analyzed changes in the discharge planning ability of the 62 nurses without home visit experience after the case conferences.Results: Ward nurses with experience in home visits before discharge had significantly higher discharge planning ability than those without such experience. After a case conference, the discharge planning ability significantly changed for nurses without experience in home visits. Their attitude toward home care changed, and they recognized its importance, associating it with the words "poor-rich", "dirty-clean", and "confined-free". They also scored higher on the Discharge Planning Process Evaluation Measurement (DCP-PEM) for "understands the importance of educating the patient's family", and "devises a plan taking health care needs into account", and on the Discharge Planning Process Scale for hospital ward nurses for "makes contact with a care manager as early as possible".Conclusions: Involving ward nurses in home visits before discharge and case conferences with visiting nurses were effective educational methods to improve their discharge planning ability in the affective and psychomotor domain.

Introduction: To clarify the gap between user satisfaction with home-visit nursing services and nurses' recognition of such satisfaction.Methods: A questionnaire survey on user satisfaction with home-visit nursing services was conducted involving 716 users and 112 nurses in charge, and the obtained data were analyzed to calculate the agreement rate between the users' satisfaction and the nurses' recognition.Results: The response rate was 61.1%. In total, 438 respondents were analyzed. Many users chose as an unsatisfactory nursing point. The percent agreement for satisfaction was 93.2%. The prevalence- and bias-adjusted kappa was 0.863. The users were satisfied and deemed so by the nurses in 92.5% of all cases, the former were not satisfied and deemed so by the latter in 0.7%, and the former were not satisfied, but they were deemed satisfied by the latter in 1.6%.Conclusion: This survey clarified nursing points not satisfying home-visit nursing service users, and the gap between users' satisfaction with these services and nurses' recognition of such satisfaction.

Purpose: The purpose of this study was to develop an interprofessional collaboration (IPC) scale for home health care for frail elderly. Methods: The first items of the IPC scale included collaboration members' attitudes, awareness, motivation, team strength, communication, relationships, information, care recipients' interests, effects, development, utilization of social resources, contributions to the community, and crisis management. The subjects were 512 care managers who work in home care support offices across Japan. They manage interprofessional collaboration in home health care for frail elderly who need care at 65 years old and above. The scale's construct validity, internal consistency, the validity of known groups, concurrent validity, and test-retest reliability (193 subjects) were examined. Results: The final IPC scale's items consisted of four factors (37 items): the strength of interprofessional teams (16), the management of collaborative systems (7), effects of collaboration (8), and communication (6). Four factors explained 58.6% of the total explained variance. The modified model fit of the scale achieved acceptable levels. The Cronbach's α coefficient for all items was .97. The sum of communication factor in the cities/wards group was lower than those in the towns/villages group. There were differences between the sum and each factor with different levels of ease to collaborate. The intraclass correlation coefficient for all items in the first and second assessments was .875. Conclusions The validity and reliability of the IPC scale have been verified. This scale can be used to assess the IPC for home health care for frail elderly.