护理干预与老年癌症患者:特定科学与循证实践
Nursing intervention and older adults who have cancer: specific science and evidence based practice.
作者信息
Bourbonniere Meg, Kagan Sarah H
机构信息
Center for Gerontology and Health Care Research, Brown University, Box G-ST, Providence, RI 02912, USA.
出版信息
Nurs Clin North Am. 2004 Sep;39(3):529-43. doi: 10.1016/j.cnur.2004.02.009.
This review of a small and heterogeneous body of literature suggests intriguing and useful approaches to nursing interventions with older adults who have cancer and areas that clearly deserve greater attention in future research. Research such as that done by McCorkle and Goodwin,while disparate in design, clearly demonstrate the ability of interventions to achieve better continuity of care and appropriate treatment for physically and socially vulnerable older adults with cancer. Comparison across settings and studies that investigate similar clinical phenomena would illuminate further how to achieve more effective intervention with elders who have cancer. In studies addressing case management, comparison of work by McCorkle et al with that completed by Goodwin et al suggests that programs that are longer than 4-week interventions are more likely to be beneficial than are shorter programs. Goodwin et al constructed a 12-month intervention that might be extended even further to improve continuity to older adults who may lack family/social support. Continuity may be especially important as older patients move from primary or geriatric care to surgical care to medical oncology care. Such a program also may offer added benefits in care of older adults who survive an initial cancer but require vigilant follow-up for recurrence or a second primary cancer and who may face ageist assumptions about screening and early detection of those cancers. The work of Coleman, Earp, and Powe and Weinrich underscores the necessity of understanding the precise needs of rural elders in relation to cancer. These studies strongly suggest that nurses can improve screening rates and symptom management. Rural health care may have particularly poor specialty resources for cancer and aging. Increasing oncology nurses' presence in rural communities and supporting those nurses with specific content in aging may be a successful mechanism to ameliorate these deficits. Coleman's study especially found that increasing opportunities to ensure that practice is grounded in current evidence is critical to improving evidence-based practice and avoiding misconceptions about the effects of age in cancer care. The weak effects associated with the use of lay educators to improve cancer screening behaviors strongly reinforce the influence of nurses over other personnel to carry out educational interventions. In rural and urban areas alike, the credibility and professionalism of nurses was clearly of benefit. McDougall's research highlights the effects of cancer treatment on older people's cognitive status. His intervention supports the further testing of group activities led by nurses as a way to improve aspects of memory. Clinical application of this low-risk, possibly high-benefit intervention strategy, which is congruent with current work in dementia care, implies that elder care facilities might benefit from having a nurse on staff to address institutional and individual concerns related to cognitive function among older residents with cancer. A single often unstated theme throughout these studies is the impact of the nurse-patient relationship on outcome variables for older adults at risk for or living with cancer. The nurse-patient relationship, a touchstone of practice, reminds each nurse to focus on the individual elder, to look past chronological age and cancer diagnosis to understand that individual as having a life that, though it may be decades long in time, is still to be lived each day in the manner and capacity that the person can command and desires. Knowledge of that elder will aid the nurse in asking critical questions, using existing research, adapting other relevant evidence, and intervening more effectively over the course of that relationship.
对一小批内容各异的文献进行的综述,为针对老年癌症患者的护理干预提出了有趣且实用的方法,同时也指出了一些在未来研究中显然值得更多关注的领域。像麦科克尔和古德温所开展的研究,虽然设计各不相同,但清楚地表明了干预措施能够为身体和社会层面较为脆弱的老年癌症患者实现更好的护理连续性及恰当治疗。对研究相似临床现象的不同环境和研究进行比较,将进一步阐明如何对老年癌症患者进行更有效的干预。在涉及病例管理的研究中,将麦科克尔等人的工作与古德温等人完成的工作相比较,结果表明,为期超过4周的干预项目比短期项目更有可能带来益处。古德温等人构建了一个为期12个月的干预项目,甚至可能进一步延长,以改善那些可能缺乏家庭/社会支持的老年人的护理连续性。随着老年患者从初级或老年护理转向手术护理再到医学肿瘤护理,护理连续性可能尤为重要。这样一个项目在护理那些最初患癌后存活下来但需要对复发或第二种原发性癌症进行密切随访、且可能面临关于这些癌症筛查和早期检测的年龄歧视观念的老年人时,也可能会带来额外益处。科尔曼、厄普、鲍伊以及温里希的研究强调了了解农村老年人在癌症方面的确切需求的必要性。这些研究有力地表明,护士能够提高筛查率并改善症状管理。农村医疗保健在癌症和老龄化方面的专科资源可能特别匮乏。增加肿瘤护士在农村社区的数量,并为这些护士提供有关老龄化的具体内容支持,可能是改善这些不足的一种成功机制。科尔曼的研究特别发现,增加机会以确保实践基于当前证据,对于改善循证实践以及避免在癌症护理中对年龄影响的误解至关重要。与使用非专业教育者来改善癌症筛查行为相关的微弱效果,有力地强化了护士相对于其他人员在开展教育干预方面的影响力。在农村和城市地区,护士的可信度和专业性显然都有益处。麦克杜格尔的研究突出了癌症治疗对老年人认知状态的影响。他的干预措施支持进一步测试由护士主导的团体活动,以此作为改善记忆方面的一种方式。这种低风险、可能高收益的干预策略的临床应用,与当前痴呆症护理工作相一致,这意味着老年护理机构可能会受益于配备一名护士来处理与癌症老年居民认知功能相关的机构和个人问题。贯穿这些研究的一个常常未明确表述的共同主题,是护士与患者的关系对处于患癌风险或患有癌症的老年人的结果变量的影响。护士与患者的关系是实践的试金石,它提醒每位护士关注个体老年人,超越实际年龄和癌症诊断去理解这个人有着自己的生活,尽管其生命可能长达数十年,但仍需以个人能够掌控和期望的方式过好每一天。了解这位老年人将有助于护士提出关键问题、运用现有研究成果、采用其他相关证据,并在这种关系的过程中更有效地进行干预。