Identifying structure and aspects that ‘continuing nursing care’ used in discharge support from hospital to home care in Japan


Correspondence: Hiroko Nagae, End of Life Care in Nursing, Chiba University, Graduate School of Nursing, 1-8-1, Inohana Chuo-ku, Chiba-city, Chiba, 260-8672, Japan. Email:


This study investigated nursing practice in continuing nursing care with the aim of identifying the key factors in nursing practice during discharge support. A literature review of papers published in Japanese in 2000 and 2011 was conducted using ‘case management’, ‘care management’, ‘continuing nursing care’, ‘discharge support’, ‘discharge planning’ and ‘elderly person’ as key words. An analysis of 54 papers revealed the following five aspects of continuing nursing care: (i) a cyclical approach aimed at realising the lifestyle desired by the person concerned; (ii) management of medical conditions for lifestyle stability; (iii) support for the patient as someone who can live independently; (iv) support to raise the ability of families to care for themselves; and (v) team approach to achieve implementation of patient-centred care. Understanding these aspects allows nurses to recreate the lifestyle of patients and families and facilitate the implementation of a systematic team approach.


Continuing nursing care was defined at the 1969 Montreal International Council of Nurses Conference as a ‘system of receiving nursing care from an appropriate person at the time and in the place necessary for the individual concerned’.[1] In Japan, continuing nursing care was included in the glossary of terms of the Committee for Review of Academic Terms of the Japan Academy of Nursing Science (ATJANS) in 2011. ATJANS defines continuing nursing care as follows: ‘Continuing nursing care refers to the continuity of high-quality nursing care, both in terms of continuity of medical treatment from yesterday to today and into tomorrow for the person being cared for, and also in terms of the responsible provision of consistent nursing care regardless of changes in the place of treatment and changes in state of health’.[1] These definitions are significant in outlining the principles of continuing nursing care.

In Japan, with the increase in chronic illness, increased number of people over 65 years old and the dawning of an era in which the majority of people die in old age, systems promoting home-based medical care are undergoing rapid reformation. As a result, there is an increase in the number of people leaving medical facilities while still with a particular condition or disability, which requires medical management at home or in a welfare facility.[2] In this context, it is necessary to develop a community-based medical care system that responds to the needs of each individual seamlessly, and is adaptable to the living situation of each person through multi-professional coordination.[2] Continuing nursing care, which involves this kind of comprehensive community care, is now considered to be indispensible. However, there is still ambiguity concerning the specialty of nurses in continuing nursing care, regarding the kinds of aims held by nurses engaged in continuing nursing care, their practices, and the results or impact of their work. Consequently, there is a need to identify continuing nursing care in terms of the practices and effects of continuing nursing care by nurses, taking into account the cultural characteristics of nursing practice in Japan.

To facilitate the establishment of systems of comprehensive community care in Japan, this study used concept analysis as the method to reveal what kind of nursing practice nurses use in continuing nursing care, in particular identifying the key factors in nursing practice during discharge support.


Research methodology

Rodgers' methodology was used as the method of concept analysis.[3] According to Rodgers, concepts are governed by the social context in which each individual exists and develops accordingly. Continuing nursing care occurs in a variety of locations, such as hospital outpatient departments, in patient clinical wards, home care agencies and general physicians. Nursing practice is needed that is informed by various organizational and community cultures and rooted in specific Japanese values and culture concerning required care.

Data collection

The following method was used to elicit from the literature constituent concepts of continuing nursing care management by nurses. We retrieved Japanese articles from the Web Journal of Japan Medical Abstracts Society database. Articles published between 2000, when the Long Term Care Insurance System began in Japan, and 2011 were searched using ‘case management’, ‘care management’, ‘continuing nursing care’, ‘discharge support’, ‘discharge planning’ and ‘elderly’ as key words. From the 85 items identified, 54 items describing continuing nursing care conducted by nurses were selected for analysis (Fig. 1).

Figure 1.

Overview of review design.

Data analysis

Based on Rodgers' concept analysis method, a review sheet with the analytical perspectives of attributes, antecedents, consequences, and substitute terms showing conceptual definitions and characteristics was created. After intensive reading of all the articles, contents were extracted to a review sheet. Member checking was conducted for content abstracted from each paper, for the purposes of discriminating content validity. Elicited content was then grouped according to similarity, and categorization was carried out. Naming of categories was confirmed by all authors to ensure reliability.

Summary of articles

An analysis of the 54 articles revealed that none included a definition of continuing nursing care. In terms of research methods, 25 articles were case studies, 7 were epidemiological survey studies, 4 were qualitative studies using interviews, 17 were reports. Regarding practical case studies on continuing nursing care, the majority dealt with cases of patients being discharged from hospital to home, but there were also four cases of transfer between facilities like a nursing home, two cases of evaluation of coordination and five cases related to issues such as evaluation of screening sheets evaluating hospital discharge plans. Among articles related to specific conditions, nine dealt with schizophrenia and nine with dementia. This was followed by conditions such as femoral head fracture, terminal phase, heart disease and diabetes mellitus, but it was not possible to categorise accurately, as there was overlap in conditions. Medical treatment such as ventilator management, stoma management, and home parenteral nutrition and intravenous hyperalimentation management was raised. Also cases where family care systems were not possible, such as cases of people living alone or households comprising only elderly people (Table 1).

Table 1. Summary of articles
Types of articlesReview articleResearch articleReportsTotal
Research methods/Data collection SurveyInterviewsCase studyQuestionnaire 
Nurse 111710
ElderlyDementia 1 8 9
Schizophrenia   729
Cancer   314
Fracture 1  34
Cerebral infarction  2  2
Chronic diseases 4  15
Others (terminal phase, et al.)1 16311

Examination of related concepts

Terms linked to continuing nursing care include case management (CM), discharge support and discharge coordination. CM is essential for the implementation of personal service.[4] In practice, CM is employed primarily in fields such as the care of elderly people and those with developmental disabilities, mental health and home-based care. CM has multiple definitions[5-9] because it is employed in diverse areas, and so there is no unified concept. However, there are characteristics that are commonly emphasized. The first such characteristic is the fact that CM is a process that supports specific clients. The second is that all activities that support the client are organized collaboratively on a community basis. The third is continuing responsibility by CM with regard to the case.

One key element of CM is discharge coordination (support).[10] Traditionally, discharge planning has been completed while the patient is in the hospital. However, this is not actual CM. CM leads to the provision of high-quality, continuing nursing care through management of implementation in diverse locations.

From another perspective, the term nursing case management (NCM) is a similar concept used in the United States. NCM was used from the latter half of the 1980s to the beginning of the 1990s. The definition and constituent elements of NCM were decided by the American Nurses Association and other organizations. A representative definition is that NCM is ‘a collaborative process of assessment, planning, implementation, coordination and measurement of various services to meet individual needs through communication with the client and effective use of local resources, ensuring quality and cost effectiveness’.[11] The context for the implementation of NCM was managed care, and the results are thought to be linked to improvement in the quality of patient care and cost-effectiveness.[12] There is a need to resolve the same issues in Japan.

An additional perspective, ‘chronic disease management’ (CDM) is a relatively new concept.[13] CDM is a nursing model focused on the provision of social services team and the management that are in accordance with the chronic care model. It has been variously categorized so far. The outcomes of CDM are aimed at the service management to the patients in coordination with the information data system and the formation of the social service team.[14, 15] CDM is a term quite similar to ‘continuing nursing care’. Comparative reviews of the two terms will be necessary hereafter.

And furthermore, none of the articles reviewed in this study addressed the issue of cost-effectiveness of continuing nursing care. Most articles are case studies dealing with cases involving complex problems; therefore, it is possible that these issues are specific to Japan.

An analysis of the articles revealed the existing six aspects in continuing nursing care (Table 2). The following six antecedent factors indicating the necessity of continuing nursing care in Japan were extracted:

  • Limits to the hospital-lead care system have emerged
  • Measures to promote policies of community and home-based health care, in a situation in which ‘care systems based in the community are not yet established’
  • There is an increase in the number of patients and families with long-term and complex health issues.
  • The emergence of ‘more complex, longer term care needs’ as an issue on the part of those receiving medical care, due to the weakening of family function
  • Segmentation of care-related hospital-lead care system
  • Issues on the professional side around the lack of team approaches to support everyday living have expanded ‘the need for team approaches aimed at community care’.
Table 2. Identified antecedents, attributes and consequences of continuing nursing care

Limits to the hospital-lead care system

  • Rapidly aging
  • Increment of patients with chronic illness
  • Health-care cost control
  • Lengthening in hospitalization

Promotion policy of community and home-based health care

  • Promoting independence support strategy
  • Promoting home medical care strategy

Increase in the number of patients and families with long-term and complex health issues

  • Necessity in continuing medical equipment management
  • Increment of patients with long-term medical condition control
  • Seriously in living function caused by the cognitive disorder
  • Increment in patients who needs daily life support
  • Increase in the number of patients with weak living support plus being handicapped
  • Weakening family care

Weakening of family function

  • Shrinking family size
  • Rising consciousness in focusing on personal lifestyle

Segmentation of care-related hospital-lead care system

  • Continuous health-care system has not been established
  • Insufficient social resources in continuous health-care
  • Insufficient knowledge of continuing health care by medical staff

Lack of team approaches to support everyday living

  • Insufficient awareness of team-based health care for living support
  • Lack of team resources in multiple occupational fields across medical facilities
  • Insufficient understanding of continuing health care by nurses

A cyclical approach aimed at realizing the lifestyle desired by the person

  • Specify the necessity for recuperation support
  • Recuperative lifestyle assessment and support focus
  • Monitoring and assessment for continuous support in response

Managing medical conditions for lifestyle stability

  • Control to stabilize the symptoms
  • Plan medical treatment methods that are feasible for the clients (patients and families)
  • Propose a lifestyle that suits the medical condition

Support for independence of the patient as someone who can live independently

Verify the wishes of patients in future recuperation centres

Support the patients in a way such that they can try doing the things that they are capable of doing

Support the patients, enabling them to understand the changes to their own life, and their own health conditions.

Support the patients so that they can find out what they can do on their own

Making efforts to provide support for improving the self-care ability of families

  • Provide support for the family in understanding the patient's hopes
  • Understand what the thinking of the patient and family is and support them to consensus-building
  • Grasp the relationship of family members and support them in finding their own roles

A team approach aimed at the realization of patient-centred care

  • Compose a team that will accommodate to their care needs
  • Share the data and create the ground for consensus-building
  • Match health-care services to the care needs
  • Build up the team spirit

Recreation of a new life for patients and their families

  • A stable life for patients and their families
  • Improvement in self-care capabilities with patients and their families
  • Creation of a new social relationship between the patient and his/her family in the community

Implementation of a systematic team approach

  • Clarification of approach methods
  • Creating a team-based health-care system

These antecedent factors are considered to be the primary causes making continuing nursing care necessary.

Cultural factors that influence the continuing nursing care undertaken by nurses involve understanding of the family system and the values attached to ‘life’ in the place and space of ‘the home’. Nurses must understand the significance of individual existence for each person in their life, and need to work with this so that the patient and family can live collaboratively (live together) in the private space of ‘the home’, while managing the medical condition. What this means is that the family should not be seen merely as carers, but that each family has itself to make major decisions about issues. Moreover, family ‘harmony’ is linked to the individual's quality of life. Consequently, in the practice of continuing nursing care, it is particularly important to work on emotional adjustments with the entire family. This collaboration facilitates mutual respect among family members as autonomous beings acquiring independence and living in local society, for the purpose of rebuilding relationships between the patient and family members and enabling an independent social life.

Attributes and consequences of continuing nursing care

The data that were extracted to the review sheet and categorized. After categorization five attributes were derived (Fig. 2). In categorizing the attribute, we focused on the nurse's actual practice.

  • A cyclical approach[16-19] aimed at realizing the lifestyle desired by the patient and their family. The development of a nursing process in which nurses engage in a process of planning and solving problems.
  • Management of medical conditions[16, 20-22] in a way that guarantees security in daily life requires nurses to switch to simple care, adapting medical management to the daily life of the person concerned through the introduction of simple, comfortable, safe methods.
  • Making efforts to ensure that the patient, who might be suffering despair and disability through the experience of illness, can find hope and regain the sense of being able to do things alone, through support for independence.[23-26]
  • Making efforts to provide support for improving the self-care ability of families,[27-29] so that they can form a consensus and find their roles as a family with respect for the wishes of the patient
  • A team approach aimed at the realisation of patient-centred care[20, 26, 30-34] involves the formation of a team that can work with the family to realize the life desired by the patient, and that formulates and implements plans accordingly.

Two consequences were identified, focusing on what is achieved as outcome by the nurse's practice. These were expressed as problem solving for patients and families and changes in professionalism and organizations.

  • The first consequence was the recreation of a new life for the patient and family, where the primary consideration in terms of capacity/ability seems to be stability in the patient's condition and stability in everyday life through restoration of activities of daily living.[26, 33, 35] Stability was followed by improvement of self-care ability of the patient and family in terms of both patient and family being autonomous,[33, 36] and also the construction with the family new social relations in order for the family to live in the local society.[20, 27, 31, 37] Consequently, what emerged was the resolution of the patient's own problems, and the creation of links with local society.
  • The second consequence was implementation of a systematic team approach. Continuing nursing care practice is based on the premise of a team approach. The methodology of continuing nursing care practice is not distinctly clear. Because of this, the importance of nursing practice that takes full account of individuality has been recognized through experience. Nurses are more aware of the satisfaction gained from well-timed intervention and the approach method are clearer.[22, 38] At the same time, multi-professional role awareness is changing, bringing greater consciousness of coordinated collaboration, and leading to the construction of systems of team care.[31, 34, 39, 40]
Figure 2.

A cyclical approach of continuing nursing care.

Limitation of the review

This study has the following limitations.

  • Because the majority of articles were mainly reports of case studies, techniques were not scientific and details were lacking, so the bias in the data is undeniable.
  • Because only articles related to Japan were used, comparison to western countries is not possible.

Nevertheless, it is thought that there is value in understanding the true situation in Japan, and that the findings contribute to the current knowledge about continuing care.

Recommendations for future inquiry

The knowledge gained from this study can show the aims and goals of everyday practice to nurses and home care nurses who carry out discharge support. Continuing nursing care is a term that has existed for a long time, but it changes with the times along with changes in medical care systems and health-care needs.[41, 42] The results of this study could become source material for nurses in re-evaluating the meaning of continuing nursing care.[43, 44] Based on this, study results may be a guide that helps nurses become aware of their own duties, and to think autonomously about what changes should be made to their own practice and to the system in order to maintain a quality lifestyle for patients and their families.


Continuing nursing care refers to activities undertaken by nurses with the aim of supporting patient and family independence. Also, CNC includes the philosophy of care that integrates medical care and everyday life in order to establish a situation in which patients living with chronic illnesses or disabilities can experience quality lives with their families. Continuing nursing care incorporates the following aspects as integrated care in a ceaseless cycle to achieve the way of living desired by the individual concerned: (i) a cyclical approach aimed at realizing the lifestyle desired; (ii) management of medical conditions for lifestyle stability; (iii) support for independence of the patient as someone who live independently; (iv) support to raise the ability of families to care for themselves; and (v) team approach to achieve implementation of patient-centred care (Fig. 2). This results in the creation of a new lifestyle by patients and families and activities that accomplish the implementation of a systematic team approach.


This study was supported by a Grant-in-Aid for Scientific Research (B) from 2010 to 2014 from the Japan Society Promotion of Science KAKENHI Grant Number (22390440).


The authors declare no conflict of interest.