Yearbook on Journal of the Japan Society of Nursing Research 2017

Difficulties Shared by Visiting Nurses Supporting People with Mental Disorders
Hiroe Hayashi
Key Words :visiting nurse
mental disorders
difficulties
home-visit nursing station
psychiatric home visiting

ABSTRACTThe purpose of this study was to shed light on difficulties shared by visiting nurses supporting people withmental disorders. Nine nurses serving at two home-visit nursing stations were individually interviewed bothformally and informally, and the data obtained were analyzed by the Modified Grounded Theory Approach(M-GTA).
The results of the study reveal that difficulties in supporting people with mental disorders receiving in-homecare fall into the following four categories: (a) difficulties in carrying out a contract, (b) difficulties in assisting
patients in their homes, (c) difficulties in establishing cooperative relations with the people concerned, and(d) difficulties in mutual support among the nurses. These four categories interact with one another andmake the problems even more difficult to solve, resulting in a situation where a visiting nurse feels a senseof isolation.
The study suggests the necessity for (a) education of visting nurses, (b) creating a special management
position responsible for the community care of people with mental disorders, and (c) establishing a systemthat enables the home-visit nursing care service to function fully.

I. Introduction

1. Research Participants
Research participants were nine nurses (seven females andtwo males whose average age was 41 years) who worked fortwo home-visit nursing stations established together withpsychiatric hospitals. Their years of nursing experience (bothhospital and home-visit nursing) ranged from four years to
31 years (Table 1).

In Japan healthcare policy toward people with mental
disorders was originally centered on hospital treatment, but
started to rely on rehabilitation facilities, and to support theircommunity life now. For example, the project for the support
to promote the deinstitutionalization of people with mental
illness1) and Assertive Community Treatment (ACT)2) is being
conducted on a trial basis in many communities. Community
care is also promoted through the revision of the medical
payment system3).
In spite of these development, home-visit nursing care forpeoples with mental disorders has not been widespread yet.
This would be because there is not enough cooperation among
psychiatric medical institutions and there are few home-visit
nurses who have experience of psychiatric nursing, so thatmany home-visit nurses do not know what to do when they
are requested to visit homes of people with mental illness4) 5).
It is reported that many home-visit nurses who support
psychiatric patients feel burdened and stress in Europe andNorth America6) 7), but in the case of Japan community careservice is insufficient8) and there are variations of types androles of community healthcare nurses in Japan9). I consider
it necessary to clarify the difficulties nurses experience
when they support people with mental disorders because
it is difficult to conduct effective nursing practice without
clarifying it. Therefore, this research attempts to do it.

Table 1. The Outline of Research ParticipantsName Station Sex

Nurse AX

M

early 50s

Nurse CX

F

late 40s

Nurse EX

Nurse B

Nurse D
Nurse F

Nurse G

Nurse H
Nurse I

II. Research Methods

Age

X

F

mid 20s

XF

mid 40sYM

mid 40s

Y

F

Y

Y

F

F

F

late 40s

mid 40s

mid 30slate 50s

Nursing Experience

about 30 years (psychiatric),
1 year (home-visit)
2 years (general),about 2 years (home-visit)
several years (general),over 10 years (psychiatric),
4 years (home-visit)
over 10 years (general),
4 years (home-visit)
2 years (psychiatric),
2 years (home-visit)
20 years (psychiatric),
5 years (home-visit)
several years (general),
3 years (home-visit)
several years (general, psychiatric),
2 years (home-visit)
over 20 years (general, psychiatric),
1 year (home-visit)

2. Methods of Data Collection
I conducted semi-structured interviews for collecting mostdata. I also engaged in participant observation for acquiring
supplemental data. The content of interviews is mainly as
follows: (1) What do you especially care about providing
support to people with mental disorders in home-visiting
nursing care; (2) What are your worries and difficulties on
nursing care; and (3) How do you work with people in otherrelevant organizations? The average interview time was 90
minutes (ranging from 40 to 180 minutes). The number ofinterviews were one time (2 subjects), two times (4 subjects),
and three times (3 subjects). Verbatim notes (A-4 size) I took

This research employed Modified Grounded Theory
Approach (M-GTA) developed by Yasuhito Kinoshita, an
approach for looking systematically at qualitative data10).
Department of Nursing, School of Health and Social Services, Saitama
Prefectural University
Corresponding author. Tel.: +81 48 973 4770; Fax.: +81 48 973 4770.
E-mail address: hayashi-hiroe@spu.ac.jp

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Yearbook on Journal of the Japan Society of Nursing Research 2017

was composed of 201 pages. I also made informal interviews
with them about the things I could not ask, the thoughts
about nursing, and the things I want to ask in participant
observation during the morning meetings, conferences, andaccompanying visits. In addition, I visited the homes of people
with mental illness with home-visit nurses and participated innursing care. I then actively interacted with them, observed
what was going on there, and provided feedback to nurses.
Data of participant observation and interviews conducted inhome-visit nursing stations and during home-visit nursing
were composed of 145 pages (A-4 size).

for concrete examples from the data and added them inthe column of concrete examples in the worksheet; and (4)I generated subcategories and categories composing therelationship among a number of concepts, and made a result
figure and a storyline.
When I made worksheets for analysis based on interviews
and participant observation as describe above, specialistsof qualitative analysis supervised my research by checking
whether the described content was valid and comparing datawith my interpretation of them.

5. Ethical Considerations
I explained to administrators and all nurses in homevisit nursing stations the purpose of research, the content
of cooperation, and ethical considerations verbally and in
written forms. I also gained the consent to participate in the
research from people with mental illness and their family
members verbally. All data of home-visit nursing stations,
their nurses, their users and users’ family members wereanonymized, and some data were modified without altering
their meaning and affecting contexts. This research wasapproved by the Research Ethics Committee of Japanese Red
Cross College of Nursing.

3. The Period of Data Collection
I collected the data of nurses working for X Home-visit
Nursing Station from November 2002 to August 2003 andconducted concept generation. I also visited Y Home-visit
Nursing Station for collecting additional data from August to
October 2005.

4. Methods of Data Analysis
M-GTA sets up an analytical theme and subjects for analysis.
The theme of this research is: What kinds of difficulties homevisit nurses experience when they support people with mental
disorders in home-visit nursing? The subjects for analysis ishome-visit nurses.
Collected data were analyzed based on the following M-GTA
methods of analysis: (1) I focused on relevant points of dataaccording to an analytical theme and subjects for analysis,
and generated concepts by interpreting them as a concrete
example; (2) New concepts were generated through theprocess of data analysis, and worksheets for analysis werealso generated in each concept; (3) I simultaneously looked

III. Results

In this section I explain the result figure (Figure 1)
generated by the M-GTA analysis. Extracted categories,
subcategories, and concepts are shown by [ ],《 》, and <>,
respectively.（ ）is a supplementary explanation for clarifying
contexts.

[dif�iculties in assisting patients in their homes]《fear and anxiety over a single-handed help》<the fear of harming oneself or others><�linch from unsanitary living environment><don't know what to do and how much to do><be dif�icult to feel the achievements of help><can't ignore><empathy for a solitary user>[dif�iculties in carrying out a contract]《ambiguous agreement》<dif�icult to gain users' understanding><dif�icult to gain the understanding of user's family members><failing to get an acceptance>[dif�iculties in mutual support among the nurses ]《supporting one another》<review of assistance><sharing one's thoughts><the limit of mutual support among colleagues><sought a consultation and advice from the third party><had to accept it><must do enough things to meet rewards>[dif�iculties in establishing cooperative relations with the people concerned]《could not support users with other relevant actors》<could not see treatment strategies><there was a disagreement on assistance policies><connecting one another without shouldering the burden by oneself><the efforts toward team approach>In�luence

ChangeFigure 1. The Structure of Difficulties Nurses Who Support Persons with Mental Disorders Have

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Yearbook on Journal of the Japan Society of Nursing Research 2017

make use of home-visiting nursing although they agreed to
its terms. Nurse C said that several users seemed to be toldthat “you can get out of the hospital if you accept home-visit
nursing, or you should receive home-visit nursing because
it is cheap by civil servants.” She also told that “contract
starts after a verbal promise such as ‘I visit your home fornursing care,’ and ‘OK,’ that is, it starts without most users’
understanding of the meaning of home-visit nursing fully.”
Nurse D told that “we sometimes hesitate to explain thenecessity of home-visit nursing because some users do not
like to talk about their diseases.” Therefore, nurses told that
“we are very careful about the conduct of nursing care whenusers are unconvinced about its necessity.”
There were also many cases in which it was <difficult togain the understanding of user’s family members>. This is thecase in which family members do not try to understand user’s
diseases and troubles occurs when nurses conduct nursing
care to patients because they are eager to achieve results.
Most nurses said that it was much more difficult to provide
help to users who lived with family members than users who
lived by himself/herself because they became tired of dealing
with users’ family members.
A user’s father talked to Nurse F in an empty room:“His behavior looks childish (user’s age was mid-30s).
What do you think about his childish attitudes? Whatis the age limit of the use of home-visit nursing forpsychotic patients. The nurse told him that “somepatients are over 50 years old.” He just said “Is thatright?” He continued to say, “I am short-tempered, so
I am a bit frustrated that he does not get well at all.
(My visit to a patient’s home with Nurse F)
There are some cases of <failing to get an acceptance> inwhich users refuse to let nurses enter their homes. Nurses
are likely to have a sense of helplessness and lose confidence
if they fail to make cooperative relationship with patients.
Of course, I feel unsure of myself in a situation andsometimes I am rejected by a user, so that staff members also become anxious about what to do (Nurse C).
In this way there had been a lot of difficulties on nursing
care for persons with mental disorders since the start ofcontracts. But nurses considered that they “can’t help but
accept” it because of their thought that it is difficult for themto continue to stay at home without their help in a community
where there are few other social services for supporting theirlives.
Then, once nursing care started, they came to think thatthey “must do something to deserve a reward.” In otherwords, they think that they must conduct nursing care andshow some results because the relationship between themis contractual and users pay the money. Administrators of
two home-visit nursing stations told that “we continue to becompelled to think that we must do something.”

1. Storyline
The difficulties of home-visit nursing for persons withmental disorders were composed of [difficulties in carryingout a contract ], [difficulties in assisting patients in theirhomes ], [difficulties in establishing cooperative relations
with the people concerned], and [difficulties in mutual
support among the nurses].
The first difficulty that arose between nurses andusers of a home-visit nursing station was [difficulties incarrying out a contract ]. In spite of this difficulty, nurses
had to conduct home-visit nursing care because there
was a contract relationship between them. They also felt
[difficulties in assisting patients in their homes ]. There wasalso [difficulties in establishing cooperative relations withthe people concerned ] when nurses felt the limit of nursing
psychotic patients only by themselves. Even if they tried tocooperate one another for resolving the difficulties, there
was [difficulties in mutual support among the nurses ]. Thesefour categories showed that nurses could not overcome theirdifficulties fully by their own efforts, intensifying them by
influencing each other reciprocally.
I am going to explain categories, subcategories, andconcepts by presenting their variation below.

2. [Difficulties in Carrying Out a Contract]
The difficulty nurses have can be explained by the categoryof [difficulties in carrying out a contract ] composed of thetime of contracting and the continuation of nursing care topatients after the contract. Nursing care started after an《ambiguous agreement》but nurses considered that they
<had to accept it> because they signed a contract, and cameto think that they <must do enough things to meet rewards>
once nursing care started.
An《ambiguous agreement》refers to the situation in which
nurses felt difficulty in conducting nursing care because it
starts without the agreement on the perception on homevisit nursing between users of home-visit nursing stations
and nurses. Contracts must be implemented after bothsides understand and accepted the content of contracts. But
home-visit nursing for persons with mental disorders wascontracted under an《ambiguous agreement》.
An《ambiguous agreement》includes <difficult to gain
users’ understanding>, <difficult to gain the understandingof user’s family members>, and <failing to get an acceptance>.
These three concepts showed the difficulty of nursing caredue to the insufficiency of agreements between users ofhome-visit nursing stations, their family members and nurses.
<Difficult to gain users’ understanding> means that nurses
feel difficulty in performing nursing care because users ofhome-visit nursing stations fail to feel and understand thenecessity of home-visit nursing even if nurses explain it
because they are not fully aware of their own disease.
I have continued to visit one user’s home since I was
asked to see him because he did not visit a hospital. I
explained to him about the terms of home-visit nursing, but he did not requested it because it started fromthe request of our side. Therefore, our relationshiphas not developed even though I continue to visit his
home. It does not sit well, so I’m not sure whether I
should continue to conduct home-visit nursing. I think
I need to talk to his family doctor once (Nurse F).
In this way there were many cases in which nursing carestarted without users’ understanding of the necessity to

3. [Difficulties in Assisting Patients in Their Homes]
Once nursing care started, the matter can be explained by
the category of [difficulties in assisting patients in their homes ].
There was a《fear and anxiety over a single-handed help》. In
spite of this difficulty, nursing care was conducted by a senseof responsibility that we <can’t ignore> users and <empathy
for a solitary user>.
《Fear and anxiety over a single-handed help》refers to thefear for going to help a user by himself/herself and the anxiety
and apprehension over a single-handed help. It included four
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Yearbook on Journal of the Japan Society of Nursing Research 2017

feel that I must go to their homes anyway.”
Then, by going to the homes of users who are not connectedto the outside world, nurses feel that “I must do it” andconduct nursing care for them. While working in a homevisit nursing stations, they talked to users and their family
members for consultation by phone.
Nurse H went to came by to see users who lived alone andwent along with other nurses even in her holidays.
I am mostly worried about Mr. Y. I went to see him in
my Bon vacation. I also went along with other nurses
to see him. I must go to see him because nobody doesit (Nurse H).
Another factor of inducing assistance was an <empathy fora solitary user>. Many users who discharged from hospitalwere compelled to live alone because their parents had
already died and been estranged from their brothers andsisters. They were not likely to involve themselves withothers and stayed up late, making it difficult for them tomaintain community disciplines such as the rule of garbage.
Nurse H told about Mr. Y who lived at home after 30 yearsof hospitalization: “If he get hospitalized now, it would be
difficult for him to live in the community again.” Therefore,
she continued to conduct in-home care for him.

concepts: <the fear of harming oneself or others>, <flinch from
unsanitary living environment>, <don’t know what to do andhow much to do>, and <be difficult to feel the achievements ofhelp>. As these concepts show, nurses feel anxiety over doing
home-visit nursing by himself/herself.
<The fear of harming oneself or others> refers to nurse’s
perplexity and fear of doing help due to user’s violent andoppressive attitudes and acts. Nurse C told the following story
that she could take a user whose symptoms worsened to a
hospital in fear of her physical danger.
He had stopped consulting a doctor for almost two
years, but his conditions was gradually deteriorating, so I talked to his doctor about this situation andbrought him to patient’s home but he could not examine him. When I visited him, he was upset and took ahoe from a bar, shouting “why do you come here?”.
His brother then called the police, so the policeman
and I persuaded him to go to a hospital. He did notwant to be placed in a police car, so I got them to sit
in the backseat of my car and drove to the hospitalfor hospitalizing him (Nurse C).
The above fear shows that nurses felt awkward about
doing home-visit nursing alone partly due to the influence ofusers’ unsanitary living environment. <Flinch from unsanitaryliving environment> refers to a situation in which user’s living
environment is so unsanitary that it might not be good for thehealth of nurses and they might hesitate to conduct nursing
care by being intimidated by inconceivable unsanitary living
conditions. Nurse H, who were allergic to cats, talked about
coughing situations because she had to visit a user’s homewith cats.
Mr. X keeps two cats. I am allergic to cats, so it’s difficult to stay his home. I can’t stop coughing (in a car)while I go to another user’s home. I cannot change ashift time, so I am going to prepare myself for going
into his stinky house (Nurse H).
Nurses went to user’s home by motivating themselves totake care of users although they felt awkward to do it alone,but <didn’t know what to do and how much to do> there manytimes. This shows that they were of two minds about nursing
care they were conducting. They provided a variety of help
such as giving an advice on how to associate with neighbors
and preparing a simple nutritional meal with users by making
use of their experience as ordinary citizens. But they said,“it is difficult to judge the extent of help as nursing care.”and “I worry about the significance of the content of help as
nursing care and the usefulness as the contribution of user’s
independence.”
They also think that it <is difficult to feel the achievementsof help> because no change of user’s attitudes and behaviors
was observed, having a feeling of insufficiency. This showsthat nurses fail to find meaning of their own doing because
users do not change at all in spite of their assistance.
Nurses were unsure of the usefulness of assistance andtheir roles, feeling marginalized and saying that “they weresometimes at a loss as to what to do.” They also told thatthey did not feel a sense of accomplishment on assistancevery much. In this way nurses continued to conduct nursing
care on persons with mental disorders with a feeling ofincompleteness and helplessness.
Yet, they continued to conduct nursing care in spite ofdifficult by thinking that they <can’t ignore> users with afeeling of anxiety. Nurse F told that “(if I think about users) I

4. [Difficulties in Establishing Cooperative Relations with thePeople Concerned ]Through the engagement with users nurses feel that one
person is not enough to support each user, so they considered
to work with others, but it was a difficult task. This situation
can be explained by the category of [difficulties in establishingcooperative relations with the people concerned ].
Nurses felt that they《could not support users with otherrelevant actors》as [the difficulty of cooperating with relevant
actors]. More concretely, they <could not see treatment
strategies> of doctors and felt difficulty in cooperating withthem because <there was a disagreement on assistancepolicies> for users between relevant actors and nurses.
They encouraged <the efforts toward team approach> for<connecting one another without shouldering the burden by
oneself>.
I《could not support users with other relevant actors》
included two concepts: <the failure to see treatment
strategies> and <a disagreement on assistance policies>.
Relevant actors here refer to professionals who conductassistance, such as doctors and nurses in hospitals andadministrators.
<The failure to see treatment strategies> refers to asituation in which nurses do not fully understand or beconvinced of doctor’s treatment strategies, feeling unsure of
the direction of assistance.
There was a case in which home-visit nursing started
because a user’s father told that they need it although
the user had not visited a clinic very much. He does
not need medical treatment but I visited his home
under a doctor’s guidance. I asked the doctor to makea house call, but before he visited the user’s home,the doctor in charge changed. The new doctor had apolicy of providing medical care in a hospital, therefore, no doctor visited his home (Nurse F).
Some nurses said, “They are often not at home even if I
visited them. Sometimes they pretend not be at home.” They
had this kind of experience many times, so some doctors
started to doubt the necessity of home-visit nursing for
22This paper was published at “the Japan Society of Nursing Research” Vol.32 No.2 in 2009.

Yearbook on Journal of the Japan Society of Nursing Research 2017users. They wanted doctors to visit users’ homes for knowing
users’ actual situations and make use of this knowledge fortreatment. But there were few doctors who made house calls,
and nurses also accepted this situation because doctors werebusy taking care of patients in hospitals. They also thoughtthat it was not good for doctors to prescribe a lot of drugs forusers. Nurse E appeared to want to question them about it
but she could not do it. Nurses said, “doctors are just checking
items of drug instructions” and “their instructions werealways same.” In fact, there was few concrete instructions on
the Instruction of Home-visit Nursing for Psychotic Patients.
Some doctors were reluctant to write them, so there weresome cases in which nurses asked them to do it.
In addition, nurses felt that <there was a disagreement on
assistance policies> because the goals of assistance were notfully shared with other professionals. Therefore, they often
felt that their assistance to users was not effective. Nurse F
said, “There was no enough cooperation with staff membersof public health centers, so I am worried about what to do inhome-visit nursing.” Nurse C also said, “I was just exhausted.
Why must only home-visit nurses shoulder the entire burdenof the care for people with mental disorders?” She felt a gap inperception on assistance to them with nurses in hospitals, andthought the burden of home-visit nursing was heavy.
Home-visit nurses felt the difficulty of team medical carebecause they actually failed to cooperate with other relevant
actors very much. In order to overcome it, nurses tried to<connect one another without shouldering the burden by
oneself>. In other words, they realized the difficulty and limitsof home-visit nursing, therefore, it is necessary to work withother relevant actors.
In this way nurses felt the necessity of teamwork, but otherrelevant actors did not seem to feel its necessity. Therefore,
nurses tried every efforts to improve the quality of homevisit nursing for users by encouraging other relevant actors
to cooperate with them.
I got in touch with psychiatric social workers in hospitals and public health nurses in Welfare Division
for Persons with Disabilities for setting up meetings.
I asked them about a variety of things. I called themand got reports, but I said to them, “I think this judgment is not good. I think otherwise.” Then, I told that
this did not lead to a good decision, and made a newproposal... (Nurse C).
Nurses considered that they wanted to cooperate withother relevant actors for supporting users. Therefore,
they encouraged <the efforts toward team approach> byassociating with one another. This implies that nurses
make efforts to promote cooperation for assistance withprofessional teams because assistance by one nurse is notenough to support users. Nurse I talked about how she wasmaking efforts to build a solid relationship with staff members
in group homes:
When I came to work here, the relationship withgroup homes were not good. It seemed that weblamed one another. But we have begun to build agood relationship lately. Everyone (in home-visit
nursing stations) is making a lot of efforts. I also try
to show up frequently and get in touch with them(Nurse I).
In this way although they worked together to build
a cooperative relationship with one another, there is aperception gap on the assistance to users between nurses

and other relevant actors.

5. [Difficulties in Mutual Support Among the Nurses]
Nurses try to overcome a variety of difficulties by
supporting one another, but their efforts often fail. Thissituation is explained by the category of [difficulties in mutual
support among the nurses the difficulty of mutual cooperation
among nurses].
There was an aspect of《supporting one another》amongnurses in order to resolve difficulties accompanied by theassistance to users on [the difficulty of mutual cooperation
among nurses]. Nurses in a home-visit nursing station tried
to cooperate one another for overcoming difficulties, but they
were not enough to do them, so that they felt <the limit ofmutual support among colleagues>. Therefore, they <sought
a consultation and advice from the third party>, but could
not get enough of them, so they maintained their assistanceto users with difficulty.
《Supporting one another》refers to a situation in which
nurses attempt to cooperate one another for overcoming avariety of difficulties on an assistance to users. It includes
concepts of <review of assistance> and <sharing one’s
thoughts>.
<Review of assistance> refers to a situation in which eachnurse who visited a user’s home alone exchanges informationand evaluates his/her works with other nurses. They held amini conference in home-visit nursing stations quite naturally.
They all had a lively conversation about how to assist users,
and it sometimes continued even during a break. Nurse C
talked about the necessity and significance of intentional
reviewing:
Especially on home-visit nursing for people withmental disorders I always think about how to workfor users effectively. I often say, “We have to review
our own works. If not, we can’t take an initiative toimprove them. More than anyone else, we have tohave an opportunity to review our own works. Without it everyday’s busyness would make us fail to see
what we’re doing now (Nurse C).
Nurses B and F said, “We make it a rule to talk about how toassist users. But we are always not sure how we should do it.”
Nurses thought about a variety of things when they engage
in <review of assistance>. Therefore, they spontaneously<shared their thoughts> with one another in a home-visit
nursing station. This implies that they are trying to stabilize
their emotions and accept what they are by expressing their
feelings on the assistance to users and sharing their emotions.
In a home-visit nursing station nurses always talked
about users whenever they gather. Especially in lunch breakthey showed a variety of their feelings such as a feeling of
insufficiency and helplessness accompanied by assistance,
and anger at users.
Yet, they did not do what I asked to do. Many persons
with mental disorders I take care of in home-visit
nursing also have physical disorders. I provide guidance on livelihood support, daily life guidance, anddietary instruction, but they do not try to listen to me.
I had a dilemma on it. So I express my displeasure ina home-visit nursing station (Nurse D).
In particular, administrators in a home-visit nursing station
listened to their complaints even if they could not rest quietly
during lunch break. We often saw the scenes in which they
supported staff nurses when they could not find meaning in
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Yearbook on Journal of the Japan Society of Nursing Research 2017

IV. Discussion

assistance and became anxious about it in order to encouragethem to be involved with users. Administrators engaged inhome-visit nursing and psychological support for nursing
staff members. Their role as administrators were important,but it seemed that their burdens were too heavy.
《Supporting one another》was not enough to overcome
difficulties accompanied by assistance. They had to continue
to conduct assistance with difficulty.
As a measure to deal with difficulty, Nurse E said, “It may
not be a good thing, but I try not to think that I have to turn forthe better.” Nurse C told that nurses often talked about users
who did not change attitudes and behaviors at all: “What waswrong with us? What goes wrong? Is it better to ask otherorganizations to take care of them?”
In this way nurses felt <the limit of mutual support amongcolleagues>. This is a situation in which a group of nurses
cannot find out a solution, suffering hardship without
overcoming the difficulty of assistance. Nurse C faced auser’s suicide and failed to know the reason why such a thing
happened, so she was not able to recover from it for a longtime. She said she could overcome it only after she could
talk to a professor she knew. In this way it was necessary
for nurses to get an advice not from other nurses in a homevisit nursing station but from the third party for solving andovercoming difficulties.
Life-threatening incidents can occur in psychiatriccircles. Who would listen to me when such a thing
occurs? For instance, when other nurses in my officeexperience a similar incidence, I may say, “It can’t behelped.” But it doesn’t touch their heart. Don’t you
think they would say, “What, but...?” if other home-visiting nurses say, “It can’t be helped.” If people in otherorganizations say, “It can’t be helped. Such a thing
sometimes occur. I know what you went through,” I
would easily accept it and say, “Yeah.” But there wasno environment in which we can get an advice fromthe third party (Nurse C).
Therefore, nurses could not become confident of thecontinuation of assistance by themselves, so they <sought
a consultation and advice from the third party>. But theyusually could not get enough of them.
In this way home-visit nurses who assist persons withmental disorders faced a challenge from the first stage ofdeveloping a contractual relationship with users. Whenassistance starts, they felt anxious of doing an assistancealone and having a relationship with users by receiving moneyfrom them. They had worries and doubts on the assistance
relationship with users and its content. Furthermore,they sometimes felt the difficulty in cooperating withother relevant actors. Each nurse tried to overcome these
difficulties by cooperating with one another, but without
reaching a fundamental solution, they were always compelled
to continue assistance with difficulty. Even veteran Nurse I
said, “I continue to work while searching for the best way ofworking, I sometimes suddenly begin to lose my confidence.”
In this way nurses felt powerlessness, emptiness, and fatigue
on the assistance to users.
Nurses could not feel a connection with users and theirfamily members fully and were tired of continuing assistancebecause they felt the limit of mutual support among nurses
and could not also get enough cooperation and support fromother relevant actors.

1. “Contracts” on Home-Visit Nursing for People with Mental
Disorders
In this research service started by contracts of an《ambiguous agreement》 between users and home-visit
nurses, therefore, it was considered that nurses started
to have difficulties at the stage of contracts. They failed toagree on specific points in this contract relationship, and thisaffected the relationship between users and nurses, nursing
care, and cooperation with relevant actors in an adverse way.
First, there were things users must deal with on contract.
It seemed that they failed to show what they want on homevisit nursing at the stage of contract and did not know how
to make use of home-visit nursing very well. In other words,
they were not accustomed to telling nurses their intentions
and understanding the content of contracts fully. This is thereason why users failed to make use of home-visit nursing fully.
Next, there were things nurses must deal with on contract.
It seemed that they failed to understand users’ disease fully
and often resisted talking about it, showing that they did not
explain the service of home-visit nursing until users weresatisfied. In this way it was clarified that nurses needed to be
more serious about how to get contracts with users, such as
how to explain the necessity of home-visit nursing for them.
Yet, there are many cases in which users fail to understandthe necessity of home-visit nursing at the time of contracts,
which is often affected by the degree of their disease andhandicap. There were also cases in which the agreement
became difficult because users failed to face their own
disease properly and had problems on their daily lives. In
this case it is possible to terminate a contract with psychotic
patients, but this has a risk that might stop their treatment
and deteriorate their conditions. Therefore, the task of how
to continue home-visit nursing become more important in thefield of psychiatry than other medical fields11). Nurses in thisresearch also recognized it fully.
Third, the tasks of hospitals were clarified. Administratorsof hospitals often compelled persons with mental disorders
to accept home-visit nursing, and this was done without theattendance of home-visit nurses. It was also suggested thatthey failed to explain the necessity of home-visit nursing fully
to them. It is considered that this affected the relationshipbetween users and home-visit nurses negatively.
2. Nurses’ Stress and the Fluctuation of Their Identities
Accompanied by AssistanceAmong home-visit nursing conducted by intervening inusers’ daily life, nurses must especially be in close relation
to patients in home-visit nursing for persons with mental
disorders. For instance, when users are chronic schizophrenic
patients, the most typical users in home-visit nursing forpsychotic patients, nurses must assist them mainly not only
by managing their health and instructing the use of drugs
but also by helping them to keep their daily life smoothly.
Every assistance is indispensable for users to live theirlife at home, but nurses had often trouble distinguishingassistance from nursing care. In home-visit nursing nurses
engage in assistance alone, so they have a lot of discretionon it. Therefore, they must do it by making use of their own
experience of the everyday life. This can be not only the best
part of home-visit nursing, but also its difficulty.
In this way many home-visit nurses feel difficulty only after

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Yearbook on Journal of the Japan Society of Nursing Research 2017

3. The Necessity of Support to Home-Visit Nurses
Home-visit nursing stations became the place where nurses
expressed their frustration when they came back from theservice of home-visit nursing. Unless they eliminated theiranxiety and helplessness, they would not have incentive
to visit other users’ homes for assistance. Therefore, it isnecessary for them to come to terms with their feelings forconstructing a good relationship with the next user.
In home-visit nursing nurses must leave the place with avariety of thoughts toward users because they can’t leave theplace while they are working even if their relationship withusers deteriorates. It is also difficult to judge when assistanceshould be terminated because their relationship with users
span longer periods of time than those with patients in
hospitals. Medical conditions of psychotic patients are easy
to change, which also makes home-visit nursing difficult.
It is important to maintain the close relationship amongnurses and peer support among them for overcoming these
difficulties. Komatsu15) noted that she talked to her colleagues
about support and the influence of stress on herself andher life through her own practice not by intention but by
necessity. Tanifuji16) also stated that she eliminated anxiety
and an uncomfortable feeling by clarifying the basis of carethrough discussions with other staff members in order toprepare for the next home-visit nursing.
This research also revealed that nurses talked with one
another about users, their family members, and other things
about troubles and bruises caused by home-visit nursing ina home-visit nursing station. Each nurse talked about one’s
own feelings at ease freely and listened to other nurses withcompassion. It seems to affect nurses’ attempt to gain energy
for visiting users’ homes and the maintenance and recovery ofties and a feeling of trust with other nurses, users, and otherrelevant actors.
But, nurses often failed to express their own feelings
toward other nurses fully and some problems continued
to be unresolved. In other words, there was <the limit ofmutual support among colleagues> by each nurse in a homevisit nursing station, therefore, they sought the third party’s
support.
Yet, there are many problems on the treatment ofadministrators and staff members and working environment
in a home-visit nursing station17). Home-visit nurses have
tried to deal with them, but it has not yet built a frameworkthat support them. Therefore, many home-visit nurses were
exhausted and resigned their jobs. This is considered to be aserious social problem now, so it is urgent to develop a systemthat supports nurses by the third party.

they work at hospitals. This suggests the reason why they
feel difficulty in converting nursing at a hospital to nursing
at a patient’s home. Assistance starts when users choose
the service of home-visit nursing in home-visit nursing.
Therefore, we must confirm users’ willingness to receive
it before its start, but there were many cases in which thiswas insufficient at the stage of contract. Home-visit nurses
also felt difficulty in taking charge of patients through their
judgment with their own responsibility and cooperating with
relevant actors who worked in different places. In a hospitalward nurses cooperate with one another to take care of eachpatient and other professionals work with them by using theirprofessional skills. Yet, in the case of home-visit nursing they
are likely to be perplexed by being held responsible for all
assistance and being asked to get in touch with relevant actors
who belong to other organizations.
The second difficulty lies in the difficulty of finding out themeaning of nursing assistance. Nurses in this study provided
assistance to users for making them engage in daily life
without trouble by relying on the wisdom of their own life
experience. But they <don’t know what to do and how muchto do>, so that they were compelled to conduct nursing careby trial and error. Takei12) notes that “the work of assisting
patient’s daily life is the basic of social therapeutic roles ofpsychiatric nursing, but its results are usually not noticeable
and would not become the focus of attention by others.” Evenif nurses try their best to assist patients, there is usually nochange among them, so that their efforts are not likely to beevaluated positively. This caused their anxiety of assistanceand the feeling of undervaluation. Even if they provide avariety of consultation on daily living to them, it was not likely
to be noticeable and concrete. Therefore, they reinforced the
feeling that “is it OK to continue such an involvement?” In
addition, they were told that it is important to reach for the
self-reliance of psychotic patients but were often puzzled by
the level of assistance to users’ daily living which is necessary
for their self-reliance and felt difficulty in giving assistancefor self-support.
The third difficulty is due to the borderless situationof participants of home-visit nursing because a variety ofprofessionals are involved in it13). In this situation many
nurses seem to ponder the role of home-visit nurses on
home-visit nursing for people with mental disorders. A
variety of people engage in assistance for users, so homevisit nurses’ roles and functions became ambiguous. It was
revealed that they worried about their own assistance andtheir relationship with users while conducting assistance.
Home-visit nurses felt uncertainty about themselvesbecause they did not have confidence in assistance, doubted
about the role of nurses on this job, and failed to have enoughties with users and other relevant actors. In other words, it
is said that there was a disturbance of occupational identity
as home-visit nurses.
In this way it is considered that home-visit nursing forpeople with mental disorders is likely to cause dilemma anddisturb occupational identities among home-visit nurses. Fujii
noted that nurses fail to recognize “what is and what is not”
about home-visit nursing by themselves14). This shows thenecessity of clarifying and organizing the roles of home-visit
nursing for assistance not only to psychotic patients but also
to other kinds of patients, educating home-visit nurses, andfostering the independence of home-visit nurses throughthese attempts.

4. Tasks of Community Care System
The analysis clarified several tasks needed to be solved in
the home-visit nursing system.
The first is about the home-visit nursing directive. There
were few specific and concrete instructions on the home-visit
nursing directive for psychotic patients. Hasegawa pointed out
the following stresses relevant to doctors’ instructions toward
home-visit nurses: there was not concrete instructions, theintention of instructions was unclear, and the failure to startnursing due to the delay of the delivery of a directive18).
The periodic exchange between doctor’s instructions andreports from a home-visit nursing stations was mainly done
unilaterally by nurses. It seemed that their were frustrated by
the failure to exchange information fully with doctors.

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Yearbook on Journal of the Japan Society of Nursing Research 2017

develop a home-visit nursing system by revising medical
payment system for helping nurses to conduct home-visit
nursing smoothly. There is a limit of assistance by one nurse.
This research revealed that it was not clear who were in
charge of the conduct of care management on community
care for psychotic patients. Its institutional reform is urgent.

Nurses cannot check doctors’ instructions directly ifadministrators in a home-visit nursing station took them. This
also frustrates nurses when they start home-visit nursing.
Even worse, they are asked to practice nursing care inaccordance with users’ needs by their own judgment. In thissituation novice home-visit nurses experienced with distressthat they <don’t know what to do and how much to do> and<are difficult to feel the achievements of help>.
In a hospital ward both doctors and nurses can checkpatient’s conditions although some nurses may feel frustration
by disagreements and their relations with doctors. In homevisit nursing, however, only one nurse can check the conditionof each user. Nurses requested to make the instructions ofhome-visit nursing in a manner more consistent with patients’
daily living, but they failed to get them. This also contributed
to aggravate their anxiety and lack of confidence.
The second is the failure to allow nurses to conductassistance other than the one at patient’s home. Nurses
sometimes took users to a hospital in the service of homevisit nursing. Sometimes those who visit users’ homes could
not conduct home-visit nursing due to their absence orcancellations. They also provided consultation for user’s
family members and had phone conversations with users
and their family members for a prolonged time. These arenecessary works but it is not an assistance at users’ homes,
so the costs for them are not treated as home-visit nursing
care expenses. The third is a rule that only one nurse can visit
a user’s home from a home-visit nursing station. Therefore,
nurses had to conduct home-visit nursing alone even if they
worry about it.
There was also a task of a “team medical care.” This
research revealed that nurses tried to cooperate with otherrelevant actors on the service of home-visit nursing in orderto improve it. Yet, fruitful cooperation between them was notmaterialized. There was a gap in perception between themand administrators of a home-visit nursing station. They also
could not expect enough cooperation with administrative
organizations in the community.
They wanted other professionals to help them by using
their own professionality, but cooperation between them
was always not enough. A variety professionals of medicine
and welfare are involved in home-visit nursing but they
belong to different organizations whose working systemand schedules were also different from one another. Unlike
nursing-care insurance system, care management for persons
with disabilities fails to be conducted smoothly, compellingnurses to shoulder the main burden of it. It was difficultfor different actors to cooperate one another in a team forsupporting users because they could not do it based on thesystem of medical treatment fees.
It seems that the current home-visit nursing as a “teammedical care” cannot function well unless nurses makeadjustments for other professionals outside duty hours andundertake tasks which are not supposed to be done by nurses.
This was apparent as this research showed that nurses visitedusers’ homes and accompanied them to hospitals afterwork hours and individual efforts of nurses were crucial tocooperate with other relevant actors. They perceived thatthey were doing them in the form of volunteering, making
them think that it is difficult to conduct team medical care19).
These revealed that nurses fully recognized the importanceof team medical care on community care for psychotic
patients, but it did not work smoothly. It is necessary to

V. Implications for PracticeFirst, we clarified that contracts with users were conducted
through an《ambiguous agreement》. We need to induce
patients to recognize their own diseases at an early stageof hospitalization and the necessity of home-visit nursing
to rectify this problem. It is also necessary for them to havean opportunity to talk with home-visit nurses and medical
professionals in a hospital before concluding an agreement.
Instructions and reports of home-visit nursing would be inaccord with users’ wishes by promoting communication oncontracts and nursing help among them.
By taking these measures, doctors who provide theguidance of home-visit nursing would write the instructionof home-visit nursing by incorporating necessary informationfrom users and home-visit nurses, and nurses also provide
necessary information to doctors more actively. Nurses would
be able to offer appropriate nursing care for users by asking
users about their necessary help and getting agreements withthem repeatedly. It is also necessary to hold a joint meeting
involving community care staff before patient’s discharge
from hospital in order to enhance the awareness of relevant
actors on home-visit nursing care for people with mental
disorders.
Second, nurses felt a sense of insufficiency and helplessness
during their conduct of nursing care. It is important to hold ameeting with other nurses in a home-visit nursing station inorder to deal with it. It is significant on two points. First, thesharing of experience among nurses through conversation
would enhance a feeling of mutual trust among them. Mutual
support among nurses contributes to maintain stable nursing
care for users. It would be necessary for them to hold adebriefing session. It would help them to conduct nursing
care consciously by thinking about the significance of nursing
care they provide. Its reviewing and the sharing of its policies
would also help them to conduct an assistance to people withmental disorders with no worry by homogenizing its service
and ensuring its proper management. It is also necessary
to clarify the tasks of nursing care as home-visit nursing
and improve nurses’ skills by providing training programs
on home-visit nursing for psychotic patients for home-visit
nurses.
Third, it was clarified that nurses <sought a consultation
and advice from the third party>. It is very important for
home-visit nurses to exchange information with other nurses.
It is also necessary to keep receiving consultation from thethird party such as public health nurses who can perceive
their situations and recommend appropriate measures on
nursing care. Administrators might be exhausted by listening
to staff members’ complaints alone. They also need to receive
support from the third party. Therefore, we need to construct
a support system that can resolve these problems.
Fourth, we revealed that team medical care does notwork smoothly. Nurses’ conscious efforts to encourage
relevant actors to participate in it is indispensable, but it isalso important to construct a care system that coordinate
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Yearbook on Journal of the Japan Society of Nursing Research 2017

cooperation with them. They must hold meetings regularly forgetting to know each other in order to promote cooperation
among them. Administrative agencies such as public healthcenters must take an initiative for it.
Fifth, nurses engaged in a variety of services other thanthose defined in contracts for supporting users’ daily living.
Fundamental institutional measures need to be taken foroffering appropriate services to them.
As the fourth and fifth findings show, it is urgent that weshould restructure the institution for psychotic patients byconstructing a new care system and revising the medical
payment system.

This is a necessary step we must take for realizing home-visit
nurses’ “independent” nursing care.
Appendix

This research is a revised and expanded version of myPh.D dissertation submitted to Japanese Red Cross College
of Nursing.
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VI. The Limits and Tasks of This Study

The purpose of this research was to clarify the difficulties
nurses experience when they support people with mental
disorders. M-GTA methods of analysis was useful forshowing the total picture of the difficulty of nursing help
by making the relationship among concepts and categories
clear. Yet, we could not collect data on difficulties brought
about by nurses’ years of experience and the difference ofjob positions between administrators and staff. In the next
study, we need to conduct interviews with other subjects
with a consideration of a variety of age groups, career, andjob positions, based on concepts generated in this study andcontinue and a constant comparative analysis for making ouranalysis more sophisticated.
VII. Conclusion

In order to resolve difficulties nurses had on nursing
care for patients, medical professionals in a hospital mustencourage them to understand their own diseases and thenecessity of home-visit nursing during their hospitalization.
Medical professionals in a home-visit nursing station must
make a contract with them by forming a consensus with a helpof nurses in a hospital and checking the content of contracts
with them.
It is necessary to restructure a system that supports
home-visit nurses by reviewing working experience withother nurses and receiving consultation from the third party
to resolve their anxiety and a feeling of helplessness. It isalso necessary to carry out training seminars on home-visit
nursing for psychotic patients for making home-visit nurses
clarify the goals of nursing care in home-visit nursing andimprove their nursing skills.
The analysis also suggested the necessity to improve thesystem of home-visit nursing through the revision of the
medical payment system. We believe that the fundamental
problems of home-visit nursing can be reduced by dealing
with these defects of the current home-visit nursing system.

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