递进互动式健康教育对脑卒中后鼻饲患者家庭照护水平的影响

目的探讨递进互动式健康教育模式在提高卒中后鼻饲患者家庭照护水平上的有效性。方法选择卒中后伴吞咽功能缺损接受鼻饲护理患者的主要家庭照护者60名,随机分为实验组（n=30）和对照组（n=30）。实验组为递进互动式健康教育组,患者人院1～5d内护士讲解鼻饲相关知识和演示操作过程;6～10d讲解操作注意事项,主要照顾者演示操作过程;11—15d由主要照顾者讲解操作注意事项并在护士辅助下完成操作过程。对照组为常规健康教育组。分别在留置胃管后第15d评价两组主要家庭照护者的鼻饲技术、鼻饲相关护理知识、护理满意度,在患者出院后28d内电话随访胃管留置情况。结果实验组主要照顾者鼻饲护理知识（8．23±1．01）分,对照组（5．73±0．98）分,差异有统计学意义（t=9．75,P〈0．01）;实验组鼻饲护理技术掌握评分（38．07±2．63）分,对照组（24．53±3．40）分,差异有统计学意义（t=17．25,P〈0．01）;出院28d内胃管留置情况电话随访结果实验组优于对照组（P〈0．01）;两组护理满意度总分比较差异有统计学意义（P〈0．01）。结论递进互动式健康教育可以提高鼻饲患者主要照顾者的护理技能,改善护理技术和流程的满意度。     

Attitudes of nursing staff working with older people towards nutritional nursing care

Aim. The aim of this study was to examine attitudes of the nursing staff in geriatric care towards factors of importance for nutritional nursing care. Background. Studies show that nutritional risk assessment is seldom performed on older patients as routine and very few patients have a nutritional care plan. Patients in long‐term care who are easy to feed are also found to be looked upon more positively than those with high feeding needs. Methods. A total of 252 registered nurses and nurse aids working at geriatric rehabilitation and medical care clinics and resident homes participated in the study. Attitudes were examined using the Staff Attitudes to Nutritional Nursing Care Geriatric scale. The scale includes 18 items and was designed as a one to five‐point Lickert‐type scale. It gives a total score and five subscales representing the dimensions ‘Norms’, ‘Habits’, ‘Assessment’, ‘Intervention’ and ‘Individualization’. A higher score indicates a more positive attitude. Results. Of all nursing staff, 53% displayed a positive attitude towards factors of importance for nutritional nursing care and the rest displayed a neutral or negative attitude. The ‘Intervention’ dimension, dealing with nutritional problems and how to manage them, reflected the highest level of positive attitudes, which represents 71% of the nursing staff. The ‘Norms’ dimension had the lowest relative frequency of positive attitudes, 27%. The registered nurses held significantly more positive attitudes than the nurse aids did. Conclusions. Nutritional issues comprise an important and time‐consuming responsibility in geriatric care; however, nursing staff do not show an unequivocal positive attitude regarding this responsibility. The consequences this entails for the older patient need to be examined further. Relevance to clinical practice. Nursing staff play an important role in caring for patients who are malnourished or at risk for malnutrition. Positive attitudes might hinder the development of undernourishment or the further worsening of an already undernourished patient's condition.     

Improving networks between acute care nurses and an aged care assessment team

Background. Acute care nurses have an important role in the discharge planning of older people from hospital to home. However, few nurses understand the changing aged care system or the consequences of poor referral on the lives of older people postdischarge. Aims and objectives. This paper reports the findings of a research project, which aimed to investigate the possibilities for facilitating the transition of older people from hospital to home through improving the working relationship between nurses and members of a multidisciplinary aged care assessment team (ACAT). Design and methods. The paper reports one action research cycle from a larger project. Action research was chosen because its focus on knowledge development and action leads to practical solutions to clinical problems. The research approach included interactive forums designed to facilitate effective collaboration between the nurses and ACAT in the discharge planning of older people. Data collection strategies included audiotapes of ACAT research discussions, field notes, policy documents, referral forms and an evaluation tool. Results and conclusions. The findings illustrate that ward nurses have, at best, a limited knowledge and understanding of the aged care system, its function, or how to access services. They need assistance to develop their knowledge of services available to support older people following discharge. The conduct of interactive forums, which utilize a case study approach, facilitated such knowledge development and empowered the nurses to become more involved in discharge planning. Participation in the forums also facilitated new collaborative partnerships between the nurses and ACAT, which enhanced effective discharge planning. Relevance to clinical practice. The paper outlines practical strategies to support collaboration between ward nurses and community providers and/or multi disciplinary assessment services. It provides a list of key considerations for the development of effective ward/community networks to facilitate the discharge of older people.     

Evaluation of the effectiveness of hospital discharge planning and follow‐up in the primary care of patients with chronic obstructive pulmonary disease

Aims and objectives: To evaluate the effectiveness of protocolised intervention for hospital discharge and follow‐up in the primary care of patients with chronic obstructive pulmonary disease (COPD). Background: Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. Design: A quasi‐experimental design was adopted, with a control group and it was pseudorandomised by services. Methods: Patients with COPD admitted to two tertiary‐level public hospitals in Spain were recruited (2007–2008). The outcome variables included: readmission rate, patient satisfaction (LOPSS12), quality of life (St. George′s Respiratory Questionnaire) and level of knowledge about COPD. 48 hours after admission, both groups were evaluated by specialist coordinating nurses. At the hospital, a coordinating nurse visited each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, explain treatment, identify care problems and needs and facilitate communication between professionals. 24 hours after discharge, the coordinating nurses informed the primary care nurses about patient discharge. The two nurses made the first home visit together. There were follow‐up phone calls at 2, 6, 12 and 24 weeks after discharge. A total of 143 patients were recruited (Intervention group=56; Control group=87). Results: The results showed a significant improvement in the evolution of quality of life, at 12 and 24 weeks after discharge; the level of knowledge about COPD revealed significant differences between the groups. There were no differences according to satisfaction or readmission rate. Multivariate analysis (non‐conditional logistic regression) showed the intervention to be ineffective in reducing the readmission rate. Conclusions: The planning of discharge for patients with COPD is effective in terms of improving the patients’ quality of life and level of knowledge about the disease. Relevance to clinical practice: The characteristics of patients with COPD make it necessary to include them in hospital discharge planning programmes.     

General surgical patients' perspectives of the adequacy and appropriateness of discharge planning to facilitate health decision-making at home

Aim. To investigate general surgical patients’ perspectives of the adequacy and appropriateness of their discharge planning. Objectives. To identify any aspects of discharge planning that could be strengthened to assist people in managing their posthospital care and maintaining continuity of care. Background. Appropriate discharge planning is a priority in today's healthcare environment in which patients are discharged ‘quicker and sicker’, sometimes without home support. Adequate and appropriate discharge planning helps promote health literacy, which has benefits for both patients and their caregivers in helping them manage postsurgical recovery at home. Design. A qualitative, interpretive study was designed in which patients were interviewed at least one week after they returned home from hospital. Methods. Purposeful sampling was used to interview 13 general surgical patients from one of three hospitals (two public and one private) in New South Wales and Queensland, Australia. Data were collected in unstructured interviews and analysed using thematic analysis. Reflective analysis by individual research team members generated preliminary themes, which were then analysed collectively by all members of the research team to achieve consensus on patients’ perspectives. Results. Themes included a ‘one‐size‐fits‐all’ approach to providing discharge information; inconsistent or variable advice from different health professionals; a lack of predischarge assessment of their home and/or work conditions and the need for follow‐up assessment of patient and carer needs. Conclusions. The findings of this study illuminate the need for a more individualized approach to discharge planning, taking into account the patient's age, gender, surgical procedure and family and community support for immediate and longer‐term nursing follow‐up. Relevance to clinical practice. Patients would be more adequately prepared for their recovery period at home, by encouraging client‐centred, interdisciplinary communication between health practitioners; adopting a flexible, approach to discharge planning which is tailored to individual needs of postsurgical patients, particularly in relation to advice and information related to recovery; and encouraging and supporting adequate health literacy for self‐management.     

Practice nurses and the facilitation of self-management in primary care

Title. Practice nurses and the facilitation of self‐management in primary care. Aim. This paper is a report of a study to explore practice nurse involvement in facilitation of self‐management for long‐term conditions. Background. In the United Kingdom chronic disease services have shifted from secondary care to general practice and from general practitioners to practice nurses. A new United Kingdom General Practice contract requires adherence to chronic disease management protocols, and facilitating self‐management is recognized as an important component. However, improving self‐management is a relatively new focus and little is known about the ways in which nurses engage with patient self‐management and how they view work with patients in chronic disease clinics. Method. Semi‐structured interviews with 25 practice nurses were carried out in 2004–2005. Interviews were audio‐taped and transcribed verbatim. Analysis was informed by the ‘trajectory model’ and ‘personal construct’ theories. Findings. Main themes in the early stages of work with patients were: categorization of patients, diagnosis, and patient education. First impressions appeared to determine expectations of self‐management abilities, although these were amenable to change. Intermediate stages were ‘ways of working’ (breaking the task down, cognitive restructuring and addressing dissonance, modelling ‘good’ behaviour, encouragement, listening, involving carers and referral) and maintaining relationships with patients. However, in the longer‐term nurses seemed to lack resources beyond personal experience and intuitive ways of working for encouraging effective self‐care. Conclusion. The ways of working identified are unlikely to be sufficient to support patients’ self‐management, pointing to a need for education to equip nurses with techniques to work effectively with patients dealing with longer‐term effects of chronic illness.     

Caring in residential aged‐care. Qualitative findings from an e‐cohort sub‐study

Aim. The aim of this e‐cohort sub‐study was to explore and describe nurses’ understandings of ‘caring’ in residential aged‐care. Background. The quality of the work environment is an important issue for recruitment, retention and workforce planning. Knowledge about the people in and the place that is the residential aged‐care facility may assist with the problems surrounding the recruitment and retention of nurses in the workforce. Design. Qualitative electronic cohort sub‐study. Methods. This paper presents the qualitative research findings from an electronic cohort sub‐study of 58 registered and enrolled nurses working in the residential aged‐care sector in 2007. Data were collected through an open ended question and a qualitative content analysis was used to generate the core categories. Results. The concept of caring was grounded in and constrained by, the everyday reality of the nurses in the study. Organisational imperatives for the completion of documentation necessary for accreditation and funding combined with under‐staffing restricted the time available for caring practices. Some nurses represented residential care faculties as devoid of care, others as a place where the resident was central to their work and care. The staff perceived of themselves as an ageing workforce in need of rejuvenation and resourcing. Conclusion. The concept of caring is manifest in nurses’ language as they describe their workplace, the residents, themselves and the structures that impact on what they do. Good caring manifests itself when the residents are central to the business of the aged care facility. However, nurses in this study describe a range of restrictive factors impeding caring practices and diminishing workforce morale and motivation to create environments that can truly be called a ‘home‐away‐from‐home’ and one that all people would find acceptable. Relevance to clinical practice. These findings have implications for aged‐care sector recruitment, retention and workforce planning within residential aged‐care facilities.     

Enteral tube feeding training for nurses and care assistants

Increasing numbers of patients are enteral tube-fed in the community, often requiring community nursing support. Appropriate training facilitates effective patient care in this rapidly changing area of practice. The project described involved the development, piloting and evaluation of a validated home enteral tube-feeding training programme for community staff. Following wide consultation, four pilot days were provided (two for registered nurses and two for care assistants) which were positively evaluated. Post-training evaluation suggested the training led to beneficial changes in practice. Additional funding obtained has enabled the basic training to continue on a monthly basis for 2 years with biannual updates. Significant risks are attached to home enteral tube feeding; opportunities to integrate theory and practice in a safe environment should enhance patient care and decrease clinical risk.     

Discharge planning and follow-up care: the asphyxiated infant.

Discharge planning and follow-up care of the asphyxiated infant is a complex process. Models of discharge planning, team member responsibilities, and teaching responsibilities are components of hospital discharge plans. Special care needs of these infants may include vision, hearing, immunizations, seizures, medications, and feeding. Families and health care professionals need to be familiar with programs providing financial resources for care of the infant such as private insurance, prepaid health care, Medicaid, Medical Needy program, Children with Special Health Care Needs (CSHCN), federal legislation mandating education and services for high-risk infants (PL 99-142 and PL 99-457) and intervention programs. Families returning to Newborn Follow-up programs become acquainted with a variety of professionals and types of neonatal and infant assessments. Providing teaching materials and information regarding special health problems, services and outcome, as it becomes known, is the responsibility of the extended health care team of nurses, physicians, home health services, psychologists, and therapists.     

The needs of patients requiring home enteral tube feeding

A report by the British Artificial Nutrition Survey of the British Association for Parenteral and Enteral Nutrition has highlighted the needs of patients using home enteral tube feeding. Many are frail and elderly and require careful discharge planning from hospital and co-ordinated, multidisciplinary care in nursing homes or their own homes on return to the community.     

Caring for dying patients outside special palliative care settings: experiences from a nursing perspective

The aim of the study was to describe nurses' experiences in caring for gravely ill and dying patients outside special palliative care settings. Tape-recorded qualitative interviews were conducted with a total of nine nurses in primary home care, community care and hospitals. The interviews were analysed according to phenomenological methodology, which resulted in the three common structures: ambition and dedication, everyday encounters, and satisfaction/dissatisfaction. In the 'everyday encounters' structure, the following key constituents emerged: responsibility, cooperation, experience and knowledge, feelings, and time and resources. The results describe the nurses' high ambitions to give dying patients and their relatives high-quality care. Despite this, they experienced greater or lesser degrees of dissatisfaction because of insufficient cooperation, support, time and resources. They experienced satisfaction through contact with patients and relatives, functioning collegial cooperation, and the knowledge, experience and personal growth the care had given them. The results indicate that nurses need the resources such as time, improved methods of communication and cooperation as well as more support in order to give quality palliative care and achieve satisfaction with the outcome. The need for discussion about the conditions for giving palliative care outside the hospices and other special palliative care settings is also elucidated.     

After discharge home: a qualitative analysis of older ICU patients' experiences and care needs

Most patients in intensive care units suffer from critical diseases/injuries and are in need of life‐saving medical treatment. Recovery after such diseases/injuries may be lengthy and may vary. Little is known about older patients' own assessment of recovery following intensive care. The aim of this study was to explore and describe older patients' experiences of recovery and need of care within 2 months following discharge from hospital after being cared for in an intensive care unit. Fifteen patients 65 years or older, who had received care in an intensive care unit, were telephone‐interviewed 2 months following discharge. The interview texts were analysed using qualitative content analysis. Six themes were identified: ‘Discharge – a matter of physicians' and nurses' decisions', ‘Wanted to go home’, ‘Feeling well and feeling better, but…’, ‘Recovered or not, that is the question’, ‘In need of help from others’ and ‘In need of care’. Patients trusted in the medical experts’ assessment of their condition as regarded hospital discharge, but they also stated that they wanted to go home, as soon as possible, to their own familiar and private environment. Patients did not see the hospital as a place for recovery. Patients claimed that they were used to taking care of themselves within the limits of their strength and energy. If they need help, they first of all turn to family members or relatives. Patients who reported comorbidity did not assess themselves as recovered, while others stated that they had recovered but also suffered from a variety of discomforting symptoms.     

Review: nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding. Background. The literature reports varying nutritional practices in intensive care. Design. Systematic review. Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria. Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under‐ and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes. Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re‐evaluation of energy recommendations and improved delivery of enteral nutrition. Relevance to clinical practice. This review supports the multi‐disciplinary development and implementation of an evidence‐based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.     

Implementing an educational program to improve critical care nurses' enteral nutritional support

BackgroundAlthough international nutrition societies recommend enteral nutrition guidelines for patients in intensive care units (ICUs), large gaps exist between these recommendations and actual clinical practice. Education programs designed to improve nurses' knowledge about enteral nutrition are therefore required. In Korea, there are no educational intervention studies about evidence-based guidelines of enteral nutrition for critically ill patients.ObjectivesWe aimed to evaluate the effects of an education program to improve critical care nurses' perceptions, knowledge, and practices towards providing enteral nutritional support for ICU patients.MethodsA quasi-experimental, one-group study with a pre- and post-test design was conducted from March to April 2015. Nurses (N = 205) were recruited from nine ICUs from four tertiary hospitals in South Korea. The education program comprised two sessions of didactic lectures. Data were collected before (pre-test) and 1 month after (post-test) the education program using questionnaires that addressed nurses' perceptions, knowledge, and practices relating to providing enteral nutritional support for ICU patients.ResultsAfter the program, nurses showed a significant improvement in their perceptions and knowledge of enteral nutrition for ICU patients. There was a significant improvement in inspecting nostrils daily, flushing the feeding tube before administration, providing medication that needs to be crushed correctly, changing feeding sets, and adjusting feeding schedules.ConclusionsThe findings indicate that an enteral nutrition education program could be an effective strategy to increase critical care nurses' support for the critically ill. This education program can be incorporated into hospital education or in-service training for critical care nurses to strengthen their perceptions and knowledge of nutritional support in the ICU. This may improve the clinical outcomes of ICU patients.     

Experiences with advance care planning: nurses' perspective

jeong s.y.‐s., higgins i. & mcmillan m. (2011 ) Experiences with advance care planning: nurses’ perspective. International Journal of Older People Nursing  6 , 165–175 doi: 10.1111/j.1748‐3743.2009.00200.x Aims and objectives. The aim of this paper is to report the findings of a case study that explored the phenomenon of advanced care planning and advance care directives in residential care settings in Australia. In particular, this paper focuses on the experiences of Registered Nurses with advanced care planning and advance care directives. Background. Nurses need to know how to engage with residents and families when they invest time and effort on advanced care planning and documentation of advance care directives. Methods. A case‐study design involving participant observation, field note recording, semi structured interviews and document analysis was used. Data were collected over 7 months. Data analysis involved thematic content analysis. Findings. The factors that enhanced and inhibited the experiences of the Registered Nurses with advanced care planning were identified. The enhancing factors include; ‘it is their essence of who they are’, and ‘back‐up from family members and other nursing staff’. The inhibiting factors are ‘lack of time’, ‘a culture of do everything and don’t go there’, and ‘lack of family involvement’. Conclusion. The findings of the current study provided nurses with evidence of the positive nature of experiences of older people, family members, and nurses themselves with advanced care planning in an attempt to better implement and practise advanced care planning.     

Termination of professional responsibility: Exploring the process of discharging patients with heart failure from hospitals

Hekmatpou D, Mohammadi E, Ahmadi F, Arefi SH. International Journal of Nursing Practice 2010; 16 : 389–396
Termination of professional responsibility: Exploring the process of discharging patients with heart failure from hospitals Despite the emphasized importance of the discharge process for patients with heart failure, this process is not taken as seriously as it should be. The objective of this qualitative study is to explore the concept of discharge and its associated factors in 42 experienced patients, family members, nurses and cardiologists at two educational hospitals in Tehran, Iran. The content analysis of the data indicates that the participants consider hospital discharge as the termination of professional responsibility on the part of physicians and nurses as far as health‐care support is involved. Three themes were identified as factors related to the treating team, health‐care system and patients and their families. Adverse outcomes of inappropriate discharge planning which manifested as incompliance with ‘diet and medical regimen’ and lack of lifestyle modification were also noted. It seems proper to try and change the attitude of physicians and nurses towards the concept of discharge, and raise their sensitivity to organizing and executing discharge plans. It is also recommended that postdischarge care should be established.