利用实施科学进一步推动农村初级保健中预先医疗指示的采用和实施。
Using Implementation Science to Further the Adoption and Implementation of Advance Care Planning in Rural Primary Care.
机构信息
Delta, Assistant Professor, University of Kansas School of Nursing, Kansas City, KS, USA.
Delta, Clinical Assistant Professor, University of Kansas School of Nursing, Kansas City, KS, USA.
出版信息
J Nurs Scholarsh. 2020 Jan;52(1):55-64. doi: 10.1111/jnu.12513. Epub 2019 Sep 23.
PURPOSE
To analyze the literature on advance care planning (ACP) in primary care through the lens of implementation science, with a focus on implications for rural settings.
DESIGN
Scoping review of the literature.
METHODS
The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PsycINFO, and the Psychology and Behavioral Sciences Collection databases were searched for studies related to ACP adoption and implementation in primary care. The Theoretical Domains Framework was used to map the literature to 14 determinants that serve as barriers or facilitators to ACP. The Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors was used to analyze the stage of implementation for each of the included studies.
FINDINGS
Four steps to ACP were specified: identification, conversation, documentation, and follow-up. Determinants were identified for each step, but studies largely focused on the conversation step. Professional role and identity, environmental context and resources, and emotion were the most frequently cited determinants in initiating conversations. The identification step was largely determined by behavioral regulation. For documenting ACP, environmental context and resource determinants were most prevalent. In the few studies that addressed follow-up, providers expressed a desire for electronic reminders as a behavioral regulator to follow-up.
CONCLUSIONS
While ACP has been shown to have patient, family, and societal benefits, its uptake in primary care has been minimal. Because ACP is a complex process that is highly context dependent, implementation science is critical to inform its successful adoption and implementation. Smaller healthcare networks, adaptable professional roles, trusted relationships, and tight-knit community might be important facilitators of ACP in rural primary care.
CLINICAL RELEVANCE
Findings from this study can be used to accelerate ACP implementation in rural primary care.
目的
通过实施科学的视角分析初级保健中的预先医疗照护计划（ACP）文献，重点关注对农村环境的影响。
设计
文献范围回顾。
方法
在 Cumulative Index of Nursing and Allied Health Literature（CINAHL）、Medline、PsycINFO 和 Psychology and Behavioral Sciences Collection 数据库中搜索与初级保健中 ACP 采用和实施相关的研究。理论领域框架用于将文献映射到 14 个决定因素，这些因素是 ACP 的障碍或促进因素。公共服务部门循证实践实施概念模型用于分析纳入研究的实施阶段。
结果
明确了 ACP 的四个步骤：识别、对话、记录和跟进。为每个步骤确定了决定因素，但研究主要集中在对话步骤。专业角色和身份、环境背景和资源以及情绪是启动对话时最常被引用的决定因素。识别步骤主要由行为调节决定。在记录 ACP 方面，环境背景和资源决定因素最为普遍。在少数涉及后续行动的研究中，提供者表示希望电子提醒作为跟进的行为调节因素。
结论
尽管 ACP 已被证明对患者、家庭和社会有益，但在初级保健中的采用率很低。由于 ACP 是一个高度依赖背景的复杂过程，实施科学对于其成功采用和实施至关重要。较小的医疗保健网络、适应性强的专业角色、可信赖的关系和紧密联系的社区可能是农村初级保健中 ACP 的重要促进因素。
临床相关性
本研究的结果可用于加速农村初级保健中的 ACP 实施。
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