Bloemen-Vrencken J H A, de Witte L P, Engels J P G M, van den Heuvel W J A, Post M W M
Rehabilitation Centre Hoensbroeck, Institute for Rehabilitation Research, The Netherlands.
Int J Integr Care. 2005;5:e02. doi: 10.5334/ijic.126.
The purpose of this article is first to describe the development and content of a transmural care model in the rehabilitation sector, which aims to reduce the number and severity of health problems of people with spinal cord injury (SCI) and improve the continuity of care. Second, the purpose is to describe the applicability and implementation experiences of a transmural care model in the rehabilitation sector.
The transmural care model was developed in cooperation with the Dutch Association of Spinal Cord Injured Patients, community nurses, general practitioners, rehabilitation nurses, rehabilitation managers, physiatrists and researchers. The core component of the care model consists of a transmural nurse, who 'liaises' between people with SCI living in the community, professional primary care professionals and the rehabilitation centre. The transmural care model provides a job description containing activities to support people with SCI and their family/partners and activities to promote continuity of care. The transmural care model was implemented in two Dutch rehabilitation centres. The following three aspects, as experienced by the transmural nurses, were evaluated: the extent to which the care model was implemented; enabling factors and barriers for implementation; strength and weakness of the care model.
The transmural care model was not implemented in all its details, with a clear difference between the two rehabilitation centres. Enabling factors and barriers for implementation were found at three levels: 1. the level of the individual professional (e.g. competencies, attitude and motivation), 2. the organisational and financing level (e.g. availability of facilities and finances), and 3. the social context (the opinion of colleagues, managers and other professionals involved with the care). The most important weakness experienced was that there was not enough time to put all the activities into practice. The strength of the care model lies in the combination of support of patients after discharge, support of and cooperation with primary care professionals, and feedback of experiences to the clinical rehabilitation teams.
We recommend further improving and implementing the care model and encourage other care professionals and researchers to share their implementation experiences of follow-up care innovations for people with SCI.
本文的目的首先是描述康复领域跨壁护理模式的发展及内容，该模式旨在减少脊髓损伤（SCI）患者的健康问题数量及严重程度，并改善护理的连续性。其次，目的是描述跨壁护理模式在康复领域的适用性及实施经验。
跨壁护理模式是与荷兰脊髓损伤患者协会、社区护士、全科医生、康复护士、康复管理人员、物理治疗师及研究人员合作开发的。护理模式的核心组成部分包括一名跨壁护士，其在社区中的SCI患者、专业初级护理人员及康复中心之间“联络”。跨壁护理模式提供了一份工作描述，其中包含支持SCI患者及其家人/伴侣的活动以及促进护理连续性的活动。跨壁护理模式在两家荷兰康复中心实施。对跨壁护士所经历的以下三个方面进行了评估：护理模式的实施程度；实施的促成因素和障碍；护理模式的优点和缺点。
跨壁护理模式并未完全按其所有细节实施，两家康复中心之间存在明显差异。在三个层面发现了实施的促成因素和障碍：1. 个体专业人员层面（如能力、态度和动机）；2. 组织和融资层面（如设施和资金的可用性）；3. 社会背景（同事、管理人员及其他参与护理的专业人员的意见）。所经历的最重要缺点是没有足够时间将所有活动付诸实践。护理模式的优点在于出院后对患者的支持、与初级护理人员的支持及合作以及将经验反馈给临床康复团队。
我们建议进一步改进和实施该护理模式，并鼓励其他护理专业人员和研究人员分享他们对SCI患者后续护理创新的实施经验。
