Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship-based care

Aims: To identify the process that homecare nurses use when recognizing serious illness, engaging patients and families in goals-for-care discussions and guiding transitions to comfort-focused care. Design: Constructivist grounded theory. Methods: Semi-structured focus group interviews of 31 homecare Registered Nurses were recorded and transcribed (June–August 2019). Line-by-line coding using the constant comparative method until saturation was achieved and a grounded theory was identified. Credibility, transferability, and confirmability establish study rigor. Results: A grounded theory of relationship-based care. Nurses cogitate and act when recognizing serious illness. They have difficult conversations and support care transitions with wisdom and knowing, by identifying changes in illness trajectories and being informed and alert to diminishing quality of life. Nurses are skilled at engaging patients, families, and the team and accommodate care in the home for as long as possible, while manoeuvring through complex systems of care; ultimately relinquishing and guiding care to other providers and settings. However, nurses feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team. Conclusion: This study identifies a grounded theory to support clinical decision-making and position homecare nurses as leaders in guiding goal care discussions and transitions to comfort-focused care. These findings reinforce the importance of developing health policy that ensures care continuity in serious illness. Further research is needed to improve relationships across care settings and enhance training for the delivery of comfort-focused care in the home as changing needs emerge during serious illness management.