Müller-Staub Maria, Zigan Nicole, Händler-Schuster Daniela, Probst Sebastian, Monego Renate, Imhof Lorenz
Zürcher Hochschule für Angewandte Wissenschaften ZHAW, Institut für Pflege, Departement Gesundheit, Winterthur, Schweiz.
Städtische Gesundheitsdienste Zürich, Schweiz.
Pflege. 2015 Apr;28(2):79-91. doi: 10.1024/1012-5302/a000410.
Living with multiple chronic diseases is complex and leads to enhanced care needs. To foster integrated care a project called "Living with chronic disease" (Leila) was initiated.
The aim was to develop an Advanced Practice Nursing (APN) service in collaboration with medical centers for persons who are living with multiple chronic diseases. The following research questions were addressed: 1. What are patients' experiences, referring physicians and APNs with the Leila-Service? 2. How are referral processes performed? 3. How do the involved groups experience collaboration and APN role development?
A qualitative approach according grounded theory of Corbin and Strauss was used to explore the experiences with the Leila project and the interaction of the persons involved. 38 interviews were conducted with patients who are living with multiple chronic diseases, their APN's and the referring physicians.
The findings revealed "Being cared for and caring" as main category. The data demonstrated how patients responded to their involvement into care and that they were taken as serious partners in the care process. The category "organizing everyday life" describes how patients learned to cope with the consequences of living with multiple chronic diseases. "Using all resources" as another category demonstrates how capabilities and strengths were adopted.
The results of the cooperation- and allocation processes showed that the APN recognition and APN role performance have to be negotiated. Prospective APN-services for this patient population should be integrated along with physician networks and other service providers including community health nursing.
患有多种慢性疾病的生活很复杂，导致护理需求增加。为了促进综合护理，启动了一个名为“慢性病生活”（Leila）的项目。
目的是与医疗中心合作，为患有多种慢性疾病的人开发一项高级实践护理（APN）服务。解决了以下研究问题：1. 患者、转诊医生和APN对Leila服务的体验如何？2. 转诊流程是如何进行的？3. 参与的群体如何体验合作和APN角色的发展？
采用基于Corbin和Strauss扎根理论的定性方法，探索Leila项目的经验以及相关人员的互动。对患有多种慢性疾病的患者、他们的APN和转诊医生进行了38次访谈。
研究结果揭示了“被照顾与照顾他人”这一主要类别。数据展示了患者对参与护理的反应，以及他们在护理过程中被视为重要伙伴的情况。“安排日常生活”这一类别描述了患者如何学会应对患有多种慢性疾病的后果。“利用所有资源”作为另一类别展示了能力和优势是如何被采用的。
合作与分配过程的结果表明，APN的认可度和APN角色的履行必须进行协商。针对这一患者群体的前瞻性APN服务应与医生网络和其他服务提供者（包括社区健康护理）整合在一起。
