共享决策在严重精神障碍患者中的应用进展

共享决策被视为“以患者为中心的护理”的基本组成部分,近十年引起国外精神卫生领域的广泛关注。共享决策以患者需求为重点,加强医患双方信息交流,并提高患者在决策中的地位。共享决策可改善医疗保健的质量,提高患者满意度、治疗依从性和结局。该文综述共享决策在严重精神障碍患者中应用的概念、模型、内容、影响因素、效果并提出在该群体中实施共享决策的建议,以期为共享决策在国内严重精神障碍患者中应用提供参考。     

脑卒中患者行为决策评估量表的编制及信效度检验

目的 编制脑卒中患者行为决策评估量表并检验其信效度。 方法 基于跨理论模型、健康信念模型和行为决策相关理论等界定概念结构,通过文献回顾、半结构式访谈等初步构建量表条目池,经专家函询形成初始量表,采用认知性访谈对条目进行预测试及调整,2020年2月—10月,便利选取327例脑卒中患者进行调查,检验量表信效度。 结果 脑卒中患者行为决策评估量表包括4个维度、共30个条目,探索性因子分析累计方差贡献率为64.408%,条目采用Likert 5级评分法,4个维度分别命名为“行为改变动机”“行为改变意向”“决策因素”和“决策平衡”。量表内容效度指数为0.800~1.000;Cronbach’s α系数为0.934,折半信度为0.797,2周重测信度为0.833。 结论 脑卒中患者行为决策评估量表信效度较好,可作为评估脑卒中患者健康行为决策的有效工具。     

预防呼吸机相关性肺炎集束化护理方案的构建

目的 构建预防呼吸机相关性肺炎集束化护理方案,为ICU机械通气患者气道护理提供参考。方法 以天津市护理质控中心制订的2016版《预防呼吸机相关性肺炎集束化护理策略》为基础,检索国内外文献,拟订气道管理方案;2019年10月—12月运用德尔菲法对17名专家进行2轮函询,征询专家意见,确定集束化护理方案。结果 2轮函询问卷的有效回收率均为100%,专家熟悉程度分别为0.92、0.96,权威系数为0.82、0.89;各级指标肯德尔和谐系数为0.088~0.485,均具有统计学意义（P<0.01）。最终形成包含10项策略、38条具体措施的集束化护理方案。结论 该研究构建的预防呼吸机相关性肺炎集束化护理方案在原版策略的基础上,将预防“误吸”的理念更新为预防“微误吸”,是一套科学、可靠、全面的方案,可为ICU临床护理实践提供参考。     

ICU后综合征患者症状特征的潜在类别分析

目的 探讨ICU后综合征（post-intensive care syndrome,PICS）患者症状特征的潜在类别并分析各类别患者在人口学特征和疾病特征上的差异。 方法 采用便利抽样法,于2019年8月16日—2020年1月16日、2020年6月8日—2020年10月30日选取贵州省某三级甲等医院综合ICU的患者作为调查对象。患者转出ICU 1个月时,采用PICS相关症状评估量表对其进行电话随访。对PICS患者的症状特征进行潜在类别分析,并通过单因素分析和多项分类Logistic回归识别其潜在类别的影响因素。 结果 共纳入299例ICU患者,其中165例（55.18%）出现PICS症状。PICS患者的症状特征分为3个潜在类别,分别为“疲劳-睡眠障碍组”（44.24%）、“焦虑组”（16.97%）、“症状高发组”（38.79%）。“症状高发组”与“疲劳-睡眠障碍组”比较,PICS患者的急性生理与慢性健康状况评分Ⅱ（Acute Physiology and Chronic Health Evaluation Ⅱ,APACHE Ⅱ）越高归于“疲劳-睡眠障碍组”的概率越小（OR=0.882,P=0.001）,无呼吸系统疾病史和无气管切开归于“疲劳-睡眠障碍组”的概率较大（OR=5.443,P=0.048;OR=4.015,P=0.006）;“症状高发组”与“焦虑组”比较,PICS患者的APACHE Ⅱ越高归于“焦虑组”的概率越小（OR=0.903,P=0.027）,年龄<50岁归于“焦虑组”的概率较大（OR=3.392,P=0.025）;“疲劳-睡眠障碍组”与“焦虑组”比较,年龄<50岁的PICS患者归于“焦虑组”的概率较大（OR=4.422,P=0.005）。结论 PICS患者的症状特征存在异质性,可分为3个潜在类别。高APACHE Ⅱ、有呼吸系统疾病史和气管切开的PICS患者归为“症状高发组”的概率较大,年龄<50岁的PICS患者归为“焦虑组”的概率较大。临床医护人员应关注PICS患者症状特征的异质性,对不同类别的患者给予针对性的干预措施。     

老年女性尿失禁患者保守治疗的护理进展

以“尿失禁” “老年女性”“保守治疗”为主题检索相关文献,总结尿失禁的常见原因、诊断与评估,对保守治疗在老年女性尿失禁患者中的应用等进行综述,旨在引起医护人员对老年尿失禁患者的关注,为相关干预措施的制订提供依据。     

国外静脉血栓栓塞症预防研究的文献计量学分析

目的 分析国外静脉血栓栓塞症（venous thromboembolism,VTE）预防研究的现状及热点趋势,为国内护理人员开展临床工作及相关研究提供参考依据。 方法 检索科学网核心数据库（Web of Science Core Collection,WOSCC）中与VTE预防有关的核心期刊文献,检索时限为2005年1月1日—2020年4月27日,借助CiteSpace 5.0软件进行文献计量和聚类分析。 结果 国外VTE预防研究发文量整体呈上升趋势,主要聚焦物理预防、药物预防、并发症观察、危险人群识别、不同疾病人群VTE预防等5个方面,其中“预防持续时长”“间歇性充气加压装置”“脑卒中”“抗凝”“临床实践指南”和“新型口服抗凝药物”是目前的研究热点。 结论 VTE预防已受到国外学者的重视,建议通过将VTE预防研究的焦点具体化、拓宽VTE重点预防人群范围、制订VTE预防护理指南等方法,推动国内VTE预防护理研究的发展,并不断提高临床护理质量,减少VTE的发生。     

内科危重症患者深静脉血栓预防审查指标的制定及障碍因素分析

目的 开展内科危重症患者规范化深静脉血栓预防的循证护理,制订护理质量审查指标并分析循证护理过程中的障碍因素和促进因素。方法 以澳大利亚循证卫生保健中心“证据临床应用模式”为理论指导,组建团队,系统检索、评价并汇总证据,确立审查指标及审查方法,逐条进行质量审查,根据审查指标及审查结果分析障碍因素及促进因素,制订行动策略。结果 本研究从评估层面、预防实施层面、教育管理层面共汇总最佳证据21条,经过筛选将其中8条最佳证据作为构建审查标准的证据,制订了10条质量审查指标,障碍因素主要为系统层面评估工具缺乏,流程缺失,实践者层面预防意识薄弱。结论 本研究基于最佳证据并结合临床人员的专业判断制订的质量审查指标具有科学性可实施性,需针对障碍和促进因素实施变革,促进证据转化。     

情境模拟案例教学法对五年制高职护生护理伦理决策能力的影响

目的 探讨情境模拟案例教学法在五年制高职护生的护理伦理决策能力教学中的应用效果。方法 2017年8月—2019年1月,采用先按年级分层,再用抽签法按班级随机整群抽样法,抽取我校6个班级268名五年制高职护生,随机分为对照组和干预组,在“护理伦理学”教学中对五年制高职护生进行护理伦理决策能力的培养。对照组采用传统教学法,干预组采用情境模拟案例教学法,为期1学年。干预前后采用护理伦理决策能力问卷测量6个班五年制高职护生的护理伦理决策能力,来评价情境模拟案例教学法实施效果。结果 干预后,干预组五年制高职护生护理伦理决策能力得分为（313.96±24.07）分,高于对照组的（307.64±23.89）分,经统计分析,差异有统计学意义（t=2.154,P<0.05）。结论 情境模拟案例教学法有助于提高五年制高职护生的护理伦理决策能力,效果优于传统教学法。     

共享决策在乳腺癌患者治疗决策中的应用进展

乳腺癌作为全球第一大癌症, 其多样化的治疗方式获益与风险并存。共享决策能够尊重患者的知情权和自主权, 考虑其偏好和价值取向, 有利于患者获得最适合的治疗方案, 可降低其决策困境程度并提高其疾病知识知晓度和决策满意度。本文围绕共享决策的定义、共享决策在乳腺癌患者治疗决策中实施的影响因素、步骤、工具及临床应用效果进行综述, 旨在为共享决策在我国乳腺癌患者中的研究提供参考。     

护士对老年轻度认知障碍患者参与临床决策认知的质性研究

目的 深入了解长期护理轻度认知障碍（mild cognitive impairment,MCI）患者的护士对老年MCI患者参与临床决策的认知和建议,为促进医患共享决策提供参考。 方法 运用现象学研究法,于2020年11月—2021年2月选取13名长期护理MCI患者的护士进行半结构式深入访谈,采用Colaizzi 7步分析法对访谈资料进行分析。 结果 护士对老年MCI患者参与临床决策的认知可归纳为5个主题：①患者参与临床决策是尊重患者意愿的体现;②患者参与临床决策是综合提升护理质量的保障;③患者参与临床决策受其决策能力所限;④情绪消极应对状况影响患者参与临床决策;⑤患者参与临床决策在临床实施受阻。护士对老年MCI患者参与临床决策的建议可归纳为3个主题：①进一步激发患者的决策意识;②呼吁家属支持;③期望改善实施条件。 结论 医患共享决策具有重要的实践意义,但在临床实施中存在一定的阻碍。今后仍需加强患者的决策意识,培养护士的决策能力,完善医患共享决策的实施条件,以充分发挥护士的引导作用。     

The “elephant in the room”: using emotion management to uncover hidden discourses in interprofessional collaboration and teamwork

Abstract

Shared decision-making and interprofessional collaboration are important approaches to achieving consumer-centered care. The concept of shared decision-making has been expanded recently to include the interprofessional healthcare team. This study explored healthcare providers’ perceptions of barriers and facilitators to both shared decision-making and interprofessional collaboration in mental healthcare. Semi-structured interviews were conducted with 31 healthcare providers, including medical practitioners (psychiatrists, general practitioners), pharmacists, nurses, occupational therapists, psychologists and social workers. Healthcare providers identified several factors as barriers to, and facilitators of shared decision-making that could be categorized into three major themes: factors associated with mental health consumers, factors associated with healthcare providers and factors associated with healthcare service delivery. Consumers’ lack of competence to participate was frequently perceived by mental health specialty providers to be a primary barrier to shared decision-making, while information provision on illness and treatment to consumers was cited by healthcare providers from all professions to be an important facilitator of shared decision-making. Whilst healthcare providers perceived interprofessional collaboration to be influenced by healthcare provider, environmental and systemic factors, emphasis of the factors differed among healthcare providers. To facilitate interprofessional collaboration, mental health specialty providers emphasized the importance of improving mental health expertise among general practitioners and community pharmacists, whereas general health providers were of the opinion that information sharing between providers and healthcare settings was the key. The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environment) to implement effective shared decision-making and interprofessional collaboration in mental healthcare.     

Roles,processes, and outcomes of interprofessional shared decision-making in a neonatal intensive care unit: A qualitative study

Shared decision-making provides an opportunity for the knowledge and skills of care providers to synergistically influence patient care. Little is known about interprofessional shared decision-making processes in critical care settings. The aim of this study was to explore interprofessional team members’ perspectives about the nature of interprofessional shared decision-making in a neonatal intensive care unit (NICU) and to determine if there are any differences in perspectives across professional groups. An exploratory qualitative approach was used consisting of semi-structured interviews with 22 members of an interprofessional team working in a tertiary care NICU in Canada. Participants identified four key roles involved in interprofessional shared decision-making: leader, clinical experts, parents, and synthesizer. Participants perceived that interprofessional shared decision-making happens through collaboration, sharing, and weighing the options, the evidence and the credibility of opinions put forward. The process of interprofessional shared decision-making leads to a well-informed decision and participants feeling valued. Findings from this study identified key concepts of interprofessional shared decision-making, increased awareness of differing professional perspectives about this process of shared decision-making, and clarified understanding of the different roles involved in the decision-making process in an NICU.     

安宁疗护咨询在危重症患者中的应用进展

ICU与安宁疗护的结合,有助于提高ICU患者的生命质量,减少过度医疗。ICU安宁疗护咨询是以ICU临终患者和家属为中心,由安宁疗护咨询者提供有关症状控制、医疗决策制订和安宁疗护转诊信息的共享照护实践,是整合安宁疗护和ICU护理的有效途径。该文对ICU安宁疗护咨询的概念和内容、实施效果及障碍进行综述,为国内ICU开展安宁疗护咨询提供参考。     

ICU患者身体约束管理系统的构建与应用

目的 构建ICU患者身体约束管理系统并探讨其应用效果。方法 组建研究小组,以ICU患者身体约束评估量表为基础,构建ICU患者身体约束管理系统,系统实时采集相关数据,实现患者身体约束决策动态提醒和质量控制。选取2022年1月—6月浙江省某三级甲等医院ICU收治的216例患者为应用对象,比较系统应用后（2022年4月—6月）与应用前（2022年1月—3月）患者身体约束率、约束时长、非计划拔管发生率,并收集护士对该管理系统的满意度。结果 ICU患者身体约束管理系统应用后,身体约束率（35.19%）低于应用前（49.07%）,约束时长为45.71(16.41,121.31) h,显著低于对照组126.00(28.05,317.00) h,两组非计划拔管发生率的比较,差异无统计学意义;护士对约束管理系统的满意度得分为（4.56±0.48）分。结论 使用ICU患者身体约束管理系统有助于降低患者身体约束使用率,减少约束时长,护士对该系统的满意度较高。     

Is shared governance still relevant?

Is shared governance still relevant in this era of significant changes in healthcare? Requisites to support nurses and others are more important now than ever before. Shared decision-making is not only relevant, it is essential. The road to empowerment is not easy. Many patterns of organization and relationship must be changed forever through commitment and leadership today.     

Parent disclosure of complementary health approaches used for children with autism spectrum disorder: Barriers and facilitators

Background and objectivesComplementary health approaches (CHA) are widely used among children with autism spectrum disorder (ASD). As part of shared treatment decision-making, healthcare providers are encouraged to discuss CHA with parents of children with ASD. Yet prior research suggests that parents often do not disclose CHA used for children, and their reasons for nondisclosure are poorly understood. We, therefore, aimed to identify barriers and facilitators to parent disclosure of CHA used for children with ASD.Design and settingIn-depth interviews were conducted with 31 parents who reported that they were currently using CHA for their child’s ASD in Denver, Colorado or Portland, Oregon.ResultsWe used content analysis to identify six main themes indicating that the following factors play a role in disclosure: parents’ drive to optimize their child’s health, parent self-efficacy discussing CHA with healthcare providers, parent beliefs about the effectiveness of CHA, parent-provider relationship quality, provider attitudes and knowledge regarding CHA and ASD, and visit characteristics.ConclusionsStudy findings suggest that family and health system factors, together, influence parent disclosure of CHA used for children with ASD. Multifaceted intervention concurrently targeting the CHA-related knowledge, beliefs, and self-efficacy of parents whose children have been recently diagnosed with ASD, in addition to the CHA-related attitudes and knowledge of their healthcare providers may promote disclosure and shared treatment decision-making about the use of CHA.     

Challenges in end-of-life care in the ICU

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.     

Patient-centered advance care planning in special patient populations: a pilot study.

The purpose of this study was to assess the feasibility of a patient-centered advance care planning (PC-ACP) approach to patients with chronic illnesses and their surrogates with respect to promotion of shared decision-making outcomes-congruence between patient and surrogate, patient's decisional conflict, and knowledge of advance care planning. An experimental design was used. The settings were the heart failure, renal dialysis, and cardiovascular surgery clinics at Gundersen Lutheran Medical Center in La Crosse, WI. Twenty-seven patient-surrogate pairs participated. A 1-hour PC-ACP interview was provided to the experimental group. Only usual care was delivered to participants in the control group. Comparison of the composite scores of a Statement of Treatment Preferences indicated that congruence in decision-making for future medical treatment in patient-surrogate pairs in the treatment group was significantly higher than in the control group. Greater satisfaction with the decision-making process and less decisional conflict were demonstrated in the treatment group. The PC-ACP interview can be effective in promoting shared decision-making between patients and their surrogates and in producing greater satisfaction with the process of decision-making and less decisional conflict.