Aims: The purpose of this study was to develop a conceptual model of discharge planning by discharge planning nurses for clients returning home with high care needs. Background: In Japan, discharge planning plays an important role in the smooth and timely discharge of clients from medical facilities. Discharge planning nurses often oversee such processes, especially for clients with high care needs. However, a conceptual model that guides discharge planning nurses during the discharge planning process is currently lacking. Design: Qualitative.Methods. A constant comparative approach was used to collect and analyse data from semi-structured interviews conducted with 13 discharge planning nurses working at medical centres throughout Japan. Each discharge planning nurse described her discharge planning activities for a client with high care needs. Results: 'Creating an agreed discharge' was a core category of the discharge planning process carried out by discharge planning nurses. The process consisted of: (1) developing a blueprint, (2) reaching an agreement, (3) materialising the agreed plan and (4) sending the client home. The discharge planning nurse starts by developing a blueprint of client/family life after discharge. The blueprint guides each discharge planning nurse thereafter throughout their various activities. She or he also strives to reach an agreement with the client/family regarding the discharge plan. Discharge planning nurse activities detailed here are based on the client/family's daily life, and adjustments to the plan are made within an agreeable range.Conclusions. Developing a blueprint, revising and refining it to establish an agreed discharge plan based on the client/family's situations and preferences and coming to an agreement for further revisions and the final plan were essential in the discharge planning process. A precise projection of the client's condition, community resource knowledge, estimating family care and understanding specific client/family thoughts on returning home were vital to a successful discharge planning process. Relevance to clinical practice: These findings may be useful for the development of discharge planning guidelines.
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