患者及护理人员对影响出院指导理解与依从性因素的看法：一项定性研究
Patients' and caregivers' perspectives on factors that influence understanding of and adherence to hospital discharge instructions: a qualitative study.
作者信息
Okrainec Karen, Hahn-Goldberg Shoshana, Abrams Howard, Bell Chaim M, Soong Christine, Hart Michelle, Shea Beverley, Schmidt Sandra, Troup Amy, Jeffs Lianne
机构信息
Open Lab (Okrainec, Hahn-Goldberg, Abrams, Troup), University Health Network; Division of General Internal Medicine (Okrainec, Abrams), University Health Network; Department of Medicine (Okrainec, Abrams, Bell, Soong) and Institute for Health Policy, Management and Evaluation (Soong), University of Toronto; Division of General Internal Medicine (Bell, Soong), Mount Sinai Hospital; Department of Family and Community Medicine (Hart), Baycrest Health Sciences, Toronto, Ont.; Bruyère Research Institute (Shea) and Ottawa Hospital Research Institute (Shea); School of Epidemiology and Public Health (Shea), University of Ottawa; Bruyère Continuing Care (Schmidt), Ottawa, Ont.; Li Ka Shing Knowledge Institute (Jeffs), St. Michael's Hospital, Toronto, Ont.
出版信息
CMAJ Open. 2019 Jul 18;7(3):E478-E483. doi: 10.9778/cmajo.20180208. Print 2019 Jul-Sep.
BACKGROUND
Many patients have difficulty understanding and adhering to discharge instructions once home from hospital. We assessed patient and family caregiver perspectives on factors that influence understanding of and adherence to discharge instructions.
METHODS
We conducted a qualitative study using semistructured interviews of participants aged 18 years or more enrolled in a multicentre mixed-methods study who were discharged from 3 acute care hospitals across Ontario with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease or pneumonia. Patients were recruited between March and November 2016. We used directed content analysis to derive themes and subthemes.
RESULTS
Twenty-seven participants (16 patients and 11 family members) described 5 themes that affected their understanding of and adherence to discharge instructions: 1) the role of caregivers, 2) relationships with inpatient and outpatient health care providers, 3) previous hospital stay, 4) barriers to accessing postdischarge care and 5) system-level processes. Subthemes highlighted the importance participants attributed to who provides the instructions, the development of resilience and advocacy through previous admissions, the benefits of addressing language and physical disability barriers, reviewing instructions in a unhurried manner, and ensuring that written instructions are meaningful and actionable.
INTERPRETATION
Care transition interventions targeting improved communication are unlikely to improve understanding of and adherence to discharge instructions on their own. A patient-centred framework that promotes positive relationships with a patient's circle of care, reflects previous experiences with discharge, addresses equity barriers, and enhances strategies for patient and caregiver engagement at the time of discharge may optimize understanding and adherence once the patient is home.
背景
许多患者出院回家后难以理解和遵循出院指导。我们评估了患者及其家庭照护者对于影响出院指导理解和遵循的因素的看法。
方法
我们进行了一项定性研究，采用半结构化访谈，对象为参与一项多中心混合方法研究且年龄在18岁及以上的参与者，这些参与者从安大略省的3家急性护理医院出院，诊断为充血性心力衰竭、慢性阻塞性肺疾病或肺炎。患者于2016年3月至11月招募。我们使用定向内容分析法得出主题和子主题。
结果
27名参与者（16名患者和11名家庭成员）描述了5个影响他们对出院指导理解和遵循的主题：1）照护者的角色，2）与住院和门诊医疗服务提供者的关系，3）既往住院经历，4）获得出院后护理的障碍，5）系统层面的流程。子主题强调了参与者认为谁提供指导、通过既往住院培养适应力和自我主张、解决语言和身体残疾障碍的益处、从容地回顾指导以及确保书面指导有意义且可操作的重要性。
解读
以改善沟通为目标的护理过渡干预措施本身不太可能提高对出院指导的理解和遵循程度。一个以患者为中心的框架，促进与患者照护圈建立积极关系，反映既往出院经历，解决公平障碍，并在出院时加强患者和照护者参与的策略，可能会在患者回家后优化理解和遵循情况。
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