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Community nurses play a key role in providing continuous home care for patients with chronic diseases. However, a perfect system of responsibilities and requirements has not yet been formed, and nurses cannot provide high-quality nursing services for home-based patients. We attempted to construct an index of the scope of practice for community nurses providing home-based transitional care for patients with chronic diseases and to guide nurses in playing an active role in transitional care work. From March to May 2023, 14 representative community nurses from the Shanghai Community Health Service Center were selected for group interviews and 2 rounds of Delphi consultation. A total of 14 valid questionnaires were collected. The authority coefficients were 0.94 and 0.93, and the Kendall coefficients were 0.56 and 0.59 for the 2 rounds of expert consultation ( P

To clarify the functional orientation of community health nurses in the continuous care of patients with chronic diseases and to encourage community nurses to play their expected roles in extended nursing work. In this study, conducted from May to July 2020, the staff of Shanghai Community Health Service Center were sampled, and representative medical staff were selected for in-depth interviews and focus group discussions. Eighteen community medical staff members participated. The functions of community nurses in the continuous care of patients with chronic diseases are mainly as follows: ① undertaking individualized projects for patients’ continuous treatment, nursing and rehabilitation; ② creating “peer education” conditions for patients; ③ providing supportive care to family caregivers; and ④ participating in the whole process of family doctor team health management. The results provide a reminder for nurse managers that under the new mission, community nurses need “one specialty and multiple abilities,” appropriate nursing technology and good health management skills. The training of community nurses should better meet the practical needs of patients with chronic diseases.