Institute of Health and Society, Department of Nursing and Health Sciences, University of Oslo, Norway.
Int J Integr Care. 2010 Feb 18;10:e036. doi: 10.5334/ijic.508.
Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains.
In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be 'ready to be discharged'.
We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.
医疗体系和护士需要考虑到越来越多的人需要在自己家中接受医院后的护理。护士在虚弱患者的出院计划中扮演着关键角色。尽管已经付出了相当大的努力并专注于如何成功完成出院计划,但确保护理连续性的问题仍然存在。
在本文中,我们强调并讨论了在医院和社区护士进行出院计划互动时似乎没有充分表达的三个挑战。这三个挑战是:当地实践如何规避正式结构,护士的不同观点如何影响他们对患者出院后护理需求的评估,以及护士对“准备好出院”的含义有何不同理解。
我们提出,护士需要讨论这些挑战及其对护理的影响,以便为未来不断变化的医疗保健需求做好准备。