Post-discharge Follow-up Care: Nurses' Experience of Fostering Continuity of Care: A Qualitative Study

Hanny Handiyani1, *, Moh Heri Kurniawan2, Rr Tutik Sri Hariyati1, Tuti Nuraini1
1 Department of Basic and Fundamental Nursing, Faculty of Nursing, Universitas Indonesia, Jawa Bharat 16424, Indonesia
2 Faculty of Nursing, Universitas Indonesia, Jawa Bharat 16424, Indonesia

Article Metrics

CrossRef Citations:
Total Statistics:

Full-Text HTML Views: 576
Abstract HTML Views: 236
PDF Downloads: 305
ePub Downloads: 161
Total Views/Downloads: 1278
Unique Statistics:

Full-Text HTML Views: 329
Abstract HTML Views: 157
PDF Downloads: 245
ePub Downloads: 126
Total Views/Downloads: 857

Creative Commons License
© 2024 The Author(s). Published by Bentham Open.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Basic and Fundamental Nursing, Faculty of Nursing, Universitas Indonesia, Jawa Bharat 16424, Indonesia; Tel: +628129618072; E-mail:



In contemporary healthcare, ensuring continuity of care beyond hospitalization is imperative for optimizing patient outcomes. Post-discharge Follow-up Care (PFC) has emerged as a crucial component in this endeavor, especially with the integration of virtual platforms.


This study aims to thoroughly investigate nurses' experiences in providing Post-discharge Follow-up Care (PFC) to improve its implementation.


A descriptive qualitative study was conducted to explore nurses’ experiences of conducting nurse-led follow-up care. This study was conducted at University Hospital, involving nine nurses with experience in administering PFC. Data were collected through focus group interviews. Thematic analysis was performed to identify recurring patterns and themes within the data.


The thematic analysis yielded four overarching themes: 1) “Caring nurse virtually,” emphasizing nurses' dedication to compassionate virtual care, 2) “Constraints and limitations of continuing care,” highlighting challenges in resource management and coordination, 3) “Continuous documentation and coordination,” underscoring their vital role in seamless patient care, and 4) “Nurses’ expectation of technology features,” showing nurses' hopes for advanced features to enhance PFC.


This study provides deep insights into the experiences of nurses in delivering PFC through virtual platforms. It underscores the significance of maintaining emotional connections with patients, even in a virtual environment. The challenges faced in resource management and coordination highlight areas for potential improvement. Additionally, the study highlights the crucial role of accurate documentation and inter-team coordination in ensuring the continuity and quality of care. The nurses' expectations for technological advancements emphasize the need for ongoing innovation in healthcare delivery. These findings collectively contribute to the ongoing evolution of virtual follow-up care practices, ultimately enhancing patient outcomes and experiences beyond the hospital setting.

Keywords: Continuity of care, Follow-up care, Nurses, Post-discharge, Qualitative study, Virtual care.