Recently the elderly population is increasing and the number of aging people is expected to continue to increase. Many people hope to die in their own home  , however, not many are able to do so   .
Family caregivers experience some difficulties. Family caregivers of advanced cancer patients feel distressed along with sadness, sorrow and exhaustion, or anxiety and depression  . Family caregivers at home hospice had moderate-to-severe anxiety or similar symptoms  , and they experienced crisis, such as patient signs and symptoms, emotional distress, and burdens  . Also, Reblin, et al.  showed that caregivers had moderate levels of depression. These researches suggest the need for support for a patient and a family caregiver in home hospice. Visiting nurse is a very important role. However, there are few studies about the care or perception of home visiting nurses. Thus the present study examined the content of nursing and perception for home hospice patients with nurses who worked at a clinic which propose visiting medical care.
The participants were six nurses. The inclusion criteria were followings; they worked at clinics which proposed visiting medical treatment, they accompanied a physician and visiting medical treatments, apart from the daily visiting nurse station, their nursing experience was over five years. The exclusion criteria was that the nurse who might feel burden to talk in the interview was excluded.
The researchers recruited nurses who worked at one of four home hospice clinics where visiting medical treatments were proposed and the nurses agreed with participation.
The research interviewers visited clinics, explained about the research again, and received informed consent after agreement for participation. There were three interviewers and all had counseling certification.
The interview lasted approximately 60 minutes and was only completed once. The questions were; “How do you care for a patient and a family member when you visit their home as a nurse with a physician?” and “How do you perceive home hospice? Each nurses’ narrative was recorded by an IC recorder after getting their permission. This study was approved by the ethical boards of St. Mary’s College (June, 2017).
For the narrative data, we employed “qualitative analysis” by Funashima  based on the work of Berelson  . In narratives, we separated sentences into each shortest sentence without losing meanings, which is called as code. The similar codes were integrated into subcategories. Then similar subcategories were integrated into one category. Categories are separated into some themes. To maintain reliability, the categorization and coding were validated independently by researchers. Inconsistencies were discussed and negotiated until agreement was reached.
3.1. Contents of Care in Home Hospice
We selected categories from narratives about importance, changes, and hopes. We show the subcategory as < > and category as “ ”. A “clinic” means a “clinic which proposed visiting medical treatment”.
About the contents of care by a nurse, we chose six categories (Table 1). The category “1) Understanding a patient as a living person” included subcategories such as
3.2. Perception for Home Hospice
The nurse’s narratives were categorized into 11 groups of about four themes (Table 2).
About the theme [Environment of home hospice], there are three categories. The category “7) Time and space for listening carefully” included subcategories like
About the theme [Care of nurses], there are four categories. The category “10) Feeling of responsibility and attractiveness of work” included subcategories like
About the theme [Introduction to home hospice and continuation], there are two categories. The category “14) Hopes for home hospice by a patient and caregiver for introduction” included . The category “15) Economics and man-power to continue home care” included subcategories like
About the theme [Relationships between a hospital and a clinic], there are two categories. The category “16) The different opinions of observation among a family, a hospital and a clinic” included subcategories like
Table 1. Contents of care by a nurse.
Table 2. Perception for home hospice by a visiting medical treatment nurse.
Nurses could understand patients including their lives as a person. They can make intimate relationships between a patient or a family and staff. Relationships at home hospice may be stronger than at general hospitals. It is a beneficial point for home hospice. The category “3) Examining it a patient and caregiver live at ease” showed that people were made to feel safe to contact nurses for help at any time. Shalev, et al.  showed that caregivers in home hospice needed more information, and the nurses in this study tried to communicate with each other. Also, nurses use communication skills well. Oliver, et al.  showed that hospice nurses appear to use basic validation techniques naturally, and they use higher-level of techniques on complex occasions. Nurses in home hospice may be required to use higher-level communication technique sometimes because the number of visiting nurse is limited.
In the observation categories, nurses tried to make intimate relationships by understanding a patient and caregiver, they supported choices to continue care at home, and supported the acceptance of a loved one’s death during the diseases progress. These nursing processes may offer support for family resilience. A patient and family are confronted with the stressful or traumatic event of death, however, they have power to go through recovery; that is resilience. Nurses supported a patient and caregiver in regaining resilience. Previous studies showed that resilience is related to the quality of life (QOL). McDonald et al.  investigated the quality of life of caregivers and showed the importance of “maintaining resilience”. Moreover Yuli, et al.  showed that the resilience of caregivers of cancer patients contributed QOL to the caregiver’s burden.
Recently, the places where a patient spends time are various. About the theme [Environment of home hospice], nurses perceived that a patient at home can enjoy their time freely and sometimes hope appears. The number of patients in home hospice is not high, the place may be important to realize a good death  .
About the theme [Care of nurses], nurses with visiting medical treatments worry about the mental health of a patient and caregiver, a visiting nurse proposes mental care. Kozlov, et al.  showed that home hospice patients experience moderate-to-severe symptoms of anxiety and depression in the last week of life. Since family caregivers worry about the physical and emotional symptoms at the very end of care, support for this point may be important. Reblin, et al.  described that communication demonstrating emotional expression between cancer spouse caregivers and nurses during home hospice may have implications for caregiver depression up to a year after a patient’s death. That is, expressing emotion promotes a caregiver’s mental health. In the future, various kinds of intervention will be needed for mental health, and measurement of its effects will be also needed for evidence-based practice about home hospice.
Related to the theme [Relation between a hospital and a clinic], the category “16) The different opinions of observation among a family, a hospital and a clinic” showed the differences in opinions about places of care or observation. Recently, a patient’s intention is important, therefore, advanced care planning also seems to be important  . Nurses have an important role of talking to patients. Moreover, moving from a hospital where a patient gets medical treatment to a clinic in home hospice sometimes does not go well. Smoother transitions may be required. Also, teamwork between a visiting medical treatment clinic and a visiting nurse station is required. Limardi, et al.  showed the importance of healthcare team communication.
Nurses who work as visiting medical treatment providence understand a patient and a family as living people based on intimate relationships. They work apart from visiting nurses. They also felt the economic or man-power problems. We need to make a system which a national level system supports. Moreover, we need to measure the effects of nursing care such as quality of life or satisfaction of a patient or a family caregiver.
 Choi, J., Miyahita, M., Hirai, K., et al. (2010) Preference of Place for End-of-Life Cancer Care and Death among Bereaved Japanese Families Who Experience Home Hospice Care and Death of Loved One. Support Care Cancer, 18, 1445-1453.
 Ministry of Health, Labor and Welfare (2013).
 Jack, B.A., Baldry, C.R., Groves, K.E., et al. (2013) Supporting Home Care for the Dying: An Evaluation of Healthcare Professionals’ Perspectives of an Individually Tailored Hospice at Home Service. Journal of Clinical Nursing, 22, 2278-2286.
 Ullrich, A., Ascherfeld, L., Marx, G., et al. (2017) Quality of Life, Psychological Burden, Needs, and Satifaction during Specialized in Patien Palliative Care in Family Caregivers of Advanced Cancer Patients. BMC Palliative Care, 10, 31.
 Phongtankuel, V., Burchett, C.O., Shalev, A., et al. (2019) Perception of a Home Hospice Crisis: An Exploratory Study of Family Caregivers. Journal of Palliative Medicine.
 Reblin, M., Baucom, B.R.W., Clayton, M.F., et al. (2019) Communication of Emotion in Home Hospice Cancer Care: Implications for Spouse Caregiver Depression into Bereavement. Psychooncology, 28, 1102-1109.
 Shalev, A., Phongtankuel, V., Reid, M.C., et al. (2019) Home Hospice Caregivers Perceived Information Needs. American Journal of Hospice and Palliative Medicine, 36, 302-307.
 Oliver, D.P., Tappana, J., Washington, K.T., et al. (2019) Behind the Doors of Home Hospice Patients: A Secondary Qualitative Analysis of Hospice Nurse Communication with Patients and Families. Palliative & Supportive Care, 7, 1-5.
 McDonald, J., Swami, N., Pope, A., et al. (2018) Caregiver Quality of Life in Advanced Cancer: Qualitative Results from a Trial of Early Palliative Care. Palliative Medicine, 32, 69-78.
 Li, Y., Qiao, Y., Luan, X., Li, S. and Wang, K. (2019) Family Resilience and Psychological Well-Being among Chinese Breast Cancer Survivors and Their Caregivers. European Journal of Cancer Care, 28, e12984.
 Christensen, K.L., Winters, C.A., Colclough, Y., et al. (2019) Advance Care Planning in Rural Montana: Exploring the Nurse’s Role. Journal of Hospice & Palliative Nursing, 21, 264-271.