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.

Older adults with serious illness residing in the community are at risk for decline and death. Homecare Registered Nurses (RNs) are in an ideal position to recognize serious illness and engage older adults and their caregivers in discussions about goals for care, while guiding transitions to supportive care services such as palliative or hospice care. However, little is known about this process, or how homecare RNs act upon this information. Using a grounded theory approach, data were collected through focus group interviews with 35 RNs working in homecare. A social process rooted in relationship-based care over time was identified using the constant comparative method. RNs recognize serious illness and support care transitions by identifying changes in illness trajectories and assessing the impact of such changes on quality-of-life, adapting and accommodating care to support older adults in the home for as long as possible, communicating with the care team, engaging stakeholders, and maneuvering through complex systems of care; ultimately relinquishing care to other providers and settings. Our findings also reveal that RNs feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team in supporting the best care transition for older adults and their caregivers. Our findings reinforce the importance of promoting care continuity in homecare settings whenever possible, suggesting a critical need to develop training and team processes that support and empower RNs, so that they may lead care transitions as changing needs emerge during serious illness management of older adults.