Hays Richard B, Veitch Craig, Evans Rebecca J
School of Medicine, James Cook University, Queensland, Australia.
Rural Remote Health. 2005 Oct-Dec;5(4):473. Epub 2005 Nov 17.
A substantial proportion of health services for rural Australians is provided in rural health facilities by rurally based generalist health professionals. These services include procedural care within smaller rural hospitals, where teams of health professionals--medical practitioners, nurses and other support staff--work in teams to deliver a range of procedural services, both elective and urgent, that reduce the need for rural people to travel to major centres. Recent debate over the training of rural medical practitioners has focused on whether or not they need to provide procedural services, because current health service management policy appears to support the rationalisation and centralisation of service delivery in larger centres to contain costs and ensure high quality. Hence there is an assumption, without much evidence, that the quality of care in rural hospitals is lower than that provided in larger urban hospitals, although there is little agreement on just what aspects of care should be measured to indicate its quality. This article reports an exploration of multiple perspectives on what constitutes quality of care in rural procedural medical practice, as part of a broader study of the quality of care of a series of real clinical cases.
During the collection of a series of 91 individual patient cases involving anaesthetic, obstetric or surgical procedures conducted in small rural hospitals, interviews were conducted with several participants in each case: the rural doctors; rural nurses; the rural patients; and family members of those patients. In addition to issues pertaining to each case, interviews explored the perspectives of individuals in each group on the broader question of what constitutes quality of care in a general sense. Their comments were subjected to qualitative thematic analysis using Atlas.ti software (Muhr T, ATLAS.ti Scientific Software Development; Berlin, Germany). In order to consider how to measure rural health care, the thematic comments were then applied to a Donabedian structure/process/outcome model.
The different groups produced different views on what might determine the quality of health care in rural hospitals. The health professionals tended to focus on technical aspects of care, although the doctors and nurses had some different emphases, while the patients and their families were more concerned with access, interpersonal communication, convenience and cost. These themes appeared to be consistent with previous literature from general healthcare settings. A list of indicators is suggested for measuring the quality of rural health care.
This study has improved understanding of the differing views held by rural health professionals and rural patients in thinking about the quality of care provided in rural hospitals. Consideration of the quality of procedural rural medical care should include the needs and expectations of those living and working in a smaller, more familiar environment. This has implications for health planners, and suggests that there is a continuing need for rural health professionals to be trained to provide procedural medical services in rural hospitals, and for rural hospitals to be maintained at a standard necessary to support quality service provision.
相当一部分澳大利亚农村地区的医疗服务是由农村地区的全科医疗专业人员在农村医疗设施中提供的。这些服务包括在较小的农村医院提供的程序性护理，在那里，医疗专业人员团队（医生、护士和其他辅助人员）协同工作，提供一系列选择性和紧急的程序性服务，减少农村居民前往主要医疗中心的需求。最近关于农村医生培训的争论集中在他们是否需要提供程序性服务上，因为当前的医疗服务管理政策似乎支持在更大的中心进行服务合理化和集中化，以控制成本并确保高质量。因此，在缺乏充分证据的情况下，人们假设农村医院的护理质量低于大城市医院，尽管对于应衡量护理的哪些方面以表明其质量，人们几乎没有达成共识。本文报告了对农村程序性医疗实践中护理质量构成要素的多视角探索，这是对一系列真实临床病例护理质量进行更广泛研究的一部分。
在收集一系列91个涉及农村小医院进行的麻醉、产科或外科手术的个体患者病例过程中，针对每个病例与多名参与者进行了访谈：农村医生、农村护士、农村患者以及这些患者的家庭成员。除了与每个病例相关的问题外，访谈还探讨了每个群体中的个体对一般意义上护理质量构成这一更广泛问题的看法。使用Atlas.ti软件（Muhr T，ATLAS.ti科学软件开发公司；德国柏林）对他们的评论进行定性主题分析。为了考虑如何衡量农村医疗保健，然后将主题评论应用于多纳贝迪安结构/过程/结果模型。
不同群体对农村医院医疗保健质量的决定因素有不同看法。医疗专业人员倾向于关注护理的技术方面，尽管医生和护士有一些不同的侧重点，而患者及其家属更关注就医机会、人际沟通、便利性和成本。这些主题似乎与以往一般医疗环境中的文献一致。建议列出一份衡量农村医疗保健质量的指标清单。
本研究增进了对农村医疗专业人员和农村患者在思考农村医院提供的护理质量方面不同观点的理解。对农村程序性医疗护理质量的考量应包括生活和工作在较小、更熟悉环境中的人们的需求和期望。这对医疗规划者有启示意义，并表明持续需要培训农村医疗专业人员在农村医院提供程序性医疗服务，以及将农村医院维持在支持优质服务提供所需的标准。
