Using Narrative Medicine to Build Community Across the Health Professions and Foster Self-Care

Narrative medicine is a multidisciplinary field of inquiry and practice based on the premise that medical care takes place in the context of stories: the stories patients tell their providers, the stories providers tell each other, and the stories providers tell themselves about the work they do. Research on physicians and medical students suggests that training in narrative medicine conveys benefits, such as improved communication skills, personal growth, and job satisfaction. The role of narrative medicine in interprofessional groups has been less explored. In 2014, we started an interprofessional narrative medicine program in the Children's Center of the Johns Hopkins Hospital called AfterWards. Through literature, art, and writing, we endeavored to nurture empathy, encourage reflective practice, and build community among a diverse group of health care providers: nurses, social workers, attending physicians, residents, fellows, and child life specialists. The program meets monthly and is open to all on a volunteer drop-in basis. After 18 months, we conducted interviews of a purposeful sample of our attendees for reasons of quality improvement and to assess the program's impact. Our findings suggest that narrative medicine might have unique benefits for interprofessional teams. In a hospital environment that is often hierarchical and siloed, attending a narrative medicine group reduces isolation among health care providers, makes them feel equally valued, and provides a platform to hear diverse perspectives. By moderating the stress that arises from the emotional labor of hospital work, narrative medicine may also enhance self-care. Here, we report on our program's structure, summarize findings from our qualitative study, and provide perspectives from two nursing participants.     

护理干预对糖尿病患者的影响

目的探讨护理干预对糖尿病患者的影响。方法将40例患者随机分观察组与对照组,每组20例。观察组由主管护师对患者分别实施护理干预,对照组由护士进行常规护理。出院后6个月由责任护士对每位患者进行随访。结果观察组患者的知识掌握、自我护理能力及血糖控制效果均明显优于对照组,差异有统计学意义(P<0.05)。结论有效的护理干预措施能提高糖尿病患者的健康知识,从而提高自我护理能力,增加治疗依从性,降低并发症的发生率,提高生活质量。     

循证护理和健康教育对慢性乙型肝炎患者自我护理能力和治疗依从性的影响

目的：探讨循证护理和健康教育相结合对慢性乙型肝炎患者自我护理能力和治疗依从性的影响。方法选取2011年12月—2012年12月在某院治疗慢性乙型肝炎的患者122例,按照随机数字表法分为两组。对照组采用常规护理,干预组采用循证护理和健康教育相结合的方式。结果干预组干预后护理技能、自我概念、自我责任感、健康知识水平及自我护理能力总分分别为（26．91±5．60）,（20．08±3．01）,（19．41±2．98）,（47．84±7．41）,（113．91±13．42）分,明显优于干预前的（24．67±5．90）,（18．46±2．92）,（17．46±2．93）,（43．28±5．77）,（103．87±11．22）分,差异有统计学意义（t值分别为2．150,2．912,2．033,3．311,2．875;P＜0．05）,而对照组干预前后仅自我责任感评分差异有统计学意义（P＜0．05）,在其他维度上差异无统计学意义（P＞0．05）。出院3个月、6个月后干预组ALT值分别为（67．2±26．3）,（43．7±13．6）U／L,明显低于对照组的（95．8±31．1）,（72．4±17．5）U／L,差异有统计学意义（ t值分别为－3．020,－3．206;P＜0．05）。结论循证护理和健康教育相结合的方式可以有效地提高慢性乙型肝炎患者自我护理能力和治疗依从性。     

慢性乙肝患者自我护理能力与生活质量的相关性分析

目的：调查慢性乙肝患者自我护理能力和生活质量,并分析两者间的相关性。方法采用自我护理能力测定量表（ESCA）和健康状况调查问卷（SF-36）对100例门诊慢性乙肝患者进行自我护理能力和生活质量调查,并分析两者间的相关性,所有数据均输入统计学软件SPSS 16．0进行处理。结果慢性乙肝患者ESCA总分为（97．53±18．75）分,居于中等水平;SF-36各维度中生理功能、生理职能、躯体疼痛、总体健康得分分别为（79．8±17．5）,（65．3±32．1）,（74．6±19．9）,（55．7±18．6）分,均低于成人常模,差异均有统计学意义（t值分别为7．08,4．02,3．59,5．19;P＜0．01）;SF-36其他维度得分也均低于成人常模,差异有统计学意义（P＜0．01）;Personal相关分析显示,乙肝患者ESCA与SF-36得分均呈正相关性（r＝0．262～0．528,P＜0．05）。结论慢性乙肝患者自我护理能力和生活质量较低,提高患者自我护理能力有助于提高其健康状况,维持良好的生活质量。     

社区护理干预对老年慢性心力衰竭患者自我护理能力的影响

目的探讨老年慢性心力衰竭患者自我护理能力以及社区干预的效果。方法选择2013年1～11月在温州医科大学附属第一医院治疗的≥60岁的心力衰竭患者103例,随机分为研究组（51例）和对照组（52例）。两组护理干预前采用欧洲心力衰竭自我护理行为量表对患者的自我护理能力进行评估。研究组在出院后给予社区护理干预,并进行定期随访。干预6个月后,比较两组的再住院率、再住院次数、再住院天数以及自我护理能力评分。结果干预前,不同病程、心功能分级的患者自我护理能力评分比较,差异均有高度统计学意义（P〈0.01）。干预后,对照组再住院率（59.6%）显著高于研究组（39.2%）,对照组再住院次数[（0.93±0.25）次]显著多于研究组[（0.48±0.12）次],对照组再住院天数[（14.89±3.17）d]显著多于研究组[（5.53±1.42）d],干预后研究组自我护理评分[（27.1±6.9）分]显著低于干预前和对照组,差异均有统计学意义（P〈0.05或P〈0.01）。结论老年慢性心力衰竭患者自我护理能力相对较弱,社区护理干预能够显著改善患者的自我护理能力。     

健康教育对中心静脉导管胸腔置管患者的影响

目的 探讨健康教育对中心静脉导管（PICC）胸腔置管患者自护能力、自我效能及PICC相关并发症的影响.方法 收集晚期肿瘤伴恶性胸腔积液的患者100例,2012年5月前纳入的47例患者作为对照组,2012年5月及以后纳入的53例患者作为观察组,对照组给予常规护理及健康教育,观察组实施以提高患者自我护理能力和自我效能为目的的健康教育方案.结果 出院前观察组自我护理能力明显优于对照组,ESCA表的自护技能、责任感、自我概念、疾病健康知识得分及总分均高于对照组,差异有统计学意义（P＜0.05）.观察组置管期间自我效能量表不适症状管理、自我护理任务管理得分及总分均高于对照组,差异有统计学意义（P＜0.05）,观察组PICC依从性问卷调查得分高于对照组,差异有统计学意义（P＜0.05）.观察组置管期间导管最大流速变化值、月均非计划性导管维护次数PICC相关并发症发生率低于对照组,差异有统计学意义（P＜0.05）.结论 以认知行为干预、互动自我护理指导为主的健康教育有助于提高患者PICC置管期间自我护理技能、自我效能,降低导管阻塞及并发症发生率.     

自我护理训练对改善脊髓损伤患者情绪障碍的效果观察

目的探讨自我护理训练在脊髓损伤住院患者情绪改善方面的作用。方法38例脊髓损伤住院患者随机分为自我护理训练与常规护理两组,其中自我护理训练组（观察组,n=20）由责任护士对患者进行自我护理能力训练与培养,常规护理组（对照组,n=18）进行常规护理。两组患者入组前及入组干预后4周应用汉密尔顿抑郁量表（HamiltonDepressionScale,HAMD）和汉密尔顿焦虑量表（HamiltonAnxietyScale,HAMA）评估患者情绪,改良Barthel指数评定量表（modifiedBartheIindex,MBI）评定日常活动能力（activityofdailylivingscale,ADL）。结果与对照组相比,观察组患者在进行自我护理训练后,其抑郁、焦虑分值及MBI均有明显改善,差异具有统计学意义（P〈0．05）。结论自我护理能力的提高,能够显著改善脊髓损伤患者的情绪,提高患者的日常活动能力,促进患者早日回归家庭。     

Cost-effectiveness of a nurse facilitated,cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial

Objective

To assess the cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme for patients with heart failure compared with usual care including the un-facilitated access to the same manual, from the perspective of the NHS.

Design

Data were obtained from a pragmatic, multi-centre, randomized controlled ‘open’ trial conducted in seven centres in the UK between 2006 and 2008. Effectiveness was estimated as Quality-Adjusted Life Years. Resource use was measured prospectively on all patients using information provided by patients in postal questionnaires, case-note review, electronic record review and interviews with patients. Unit costs were obtained from the literature and applied to the relevant resource use to estimate total costs. Multiple imputation was used to handle missing data.

Results

There were no substantial differences in the utility scores between treatment groups in all follow-up assessments, in the use of medication or outpatient visits and both groups report a similar frequency of contact with health care professionals. After controlling for baseline utility and using imputed dataset, treatment was associated with a reduction in QALY of 0.004 and a additional cost of £69.49. The probability that the intervention is cost-effective for thresholds between £20,000 and £30,000 is around 45%.

Conclusions

There is little evidence that the addition of the intervention had any effect on costs or outcomes. The uncertainty around both estimates of cost and effectiveness mean that it is not reasonable to make recommendations based on cost-effectiveness alone.     

Factors influencing the ability to self-manage diabetes for adults living with type 1 or 2 diabetes

Background

Diabetes mellitus is one of the most common non-communicable long-term conditions in the world and is linked to high mortality, morbidity, loss of quality of life and high social and economic cost. Diabetes presents a serious health challenge, as it is a significant cause of ill health and premature death. Identification of barriers to self-care is critical for finding ways to reduce the adverse effects of this long-term condition.

Objective

This review identified issues that influence ability to self-care for adults living with diabetes types 1 or 2.

Design

A systematic review of qualitative research studies using the Joanna Briggs Institute (JBI) approach.

Data sources

An electronic search of Health Sciences databases for primary published qualitative studies was conducted April 2011. Reference lists of included articles were reviewed to identify other potential papers.

Review methods

Studies that investigated issues identified by individuals living with diabetes type 1 or 2 that influenced ability to self-care were analysed using a process of meta-aggregation. Meta-aggregation involves the extraction of findings, the synthesis of findings through grouping or aggregating similar findings into themes and labelling with appropriate names and a statement that defines the theme and meta-aggregating the themes into overarching syntheses. Methodological quality was assessed by two reviewers against the JBI quality appraisal criteria for qualitative studies.

Results

Thirty-seven qualitative studies were reviewed. The main issues impacting on an individual's ability to self-care were ‘communication’, ‘education’, ‘personal factors’, ‘provider issues’ and ‘support’. Multiple barriers were found to influence the day-to-day management of diabetes. Key issues related to communication with health care providers, an education programme that allowed for incremental knowledge gain and experiential and vicarious learning and the provision of culturally sensitive care.

Conclusions

People living with diabetes face many issues in their day-to-day management of the disease, compounded by vulnerability to wider situational, cultural and social issues. Self-care ability is a dynamic, evolutionary process that varies from person to person and involves moving from a disease focused existence to maximising life.