Robinson Andrew, Street Annette
Tasmanian School of Nursing, University of Tasmania, Hobart, Tasmania, Australia.
J Clin Nurs. 2004 May;13(4):486-96. doi: 10.1046/j.1365-2702.2003.00863.x.
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.
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).
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.
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.
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.
急症护理护士在老年人从医院出院回家的出院计划中发挥着重要作用。然而，很少有护士了解不断变化的老年护理系统，或者不恰当转诊对老年人出院后生活的影响。
本文报告了一项研究项目的结果，该项目旨在通过改善护士与多学科老年护理评估团队（ACAT）成员之间的工作关系，探讨促进老年人从医院过渡到家庭的可能性。
本文报告了一个更大项目中的一个行动研究周期。选择行动研究是因为其对知识发展和行动的关注能够带来临床问题的实际解决方案。研究方法包括旨在促进护士与ACAT在老年人出院计划中有效合作的互动论坛。数据收集策略包括ACAT研究讨论的录音带、实地记录、政策文件、转诊表格和一个评估工具。
研究结果表明，病房护士对老年护理系统、其功能或如何获取服务的了解充其量有限。他们需要帮助来了解出院后可用于支持老年人的服务。采用案例研究方法的互动论坛的开展促进了这种知识的发展，并使护士有能力更积极地参与出院计划。参与论坛还促进了护士与ACAT之间新的合作关系，从而加强了有效的出院计划。
本文概述了支持病房护士与社区提供者和/或多学科评估服务之间合作的实用策略。它提供了一份为建立有效的病房/社区网络以促进老年人出院而需重点考虑的事项清单。
