Plummer Sue, Hearnshaw Clare
East and North Hertfordshire NHS Trust, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire.
Int J Palliat Nurs. 2006 Apr;12(4):183-8. doi: 10.12968/ijpn.2006.12.4.21016.
The transition period between inpatient and community care is often a time of anxiety for patients receiving palliative care and their families. The team at Michael Sobell House designed and implemented a new community palliative care nursing service in order to ease the difficulties associated with moving between these settings. The new model offered short-term support for nurses trained in specialist palliative care who provide hands-on care, psychological support, night nursing or advice and support. The service supplemented existing community teams in order to offer a quick response to patient need. The service was evaluated at the end of the first year using two methods: an audit examining the first year's activity; and a questionnaire to health professionals who had used the service. Insight into the origins of referrals, the tasks performed by the outreach nurses and the aims of each patient episode were gained. Healthcare professionals' feedback was positive and gave some areas for suggested improvement. Reflections included issues relating to collaborative working between services, gaining a greater understanding of the problems associated with facilitating a home death and exploring potential areas of service expansion.
对于接受姑息治疗的患者及其家属而言，住院护理与社区护理的过渡阶段往往是一段焦虑时期。迈克尔·索贝尔之家的团队设计并实施了一项新的社区姑息护理服务，以缓解在这两种护理环境之间转换所带来的困难。新模式为接受过专科姑息护理培训的护士提供短期支持，这些护士提供实际护理、心理支持、夜间护理或建议与支持。该服务对现有社区团队起到补充作用，以便对患者需求做出快速响应。在第一年结束时，采用两种方法对该服务进行了评估：一是审查第一年活动的审计；二是向使用过该服务的卫生专业人员发放问卷。了解了转诊来源、外展护士执行的任务以及每个患者护理阶段的目标。医疗保健专业人员的反馈是积极的，并提出了一些有待改进的方面。反思内容包括与服务之间协作工作相关的问题、更深入了解促进在家中离世所涉及的问题以及探索服务扩展的潜在领域。
