Building a model for a support methodology based on expertise acquired during provision of palliative care

本研究的目的是通过分析护士的经验，特别是在提供姑息护理过程中获得的临床智慧，并利用它来改进整个过程，从而开发出一种护理方法论模型。我们以Benner的临床智慧研究方法(1999/2005)为线索，访问了20名具有三年或三年以上姑息治疗经验的护士。护士的判断和行动的特点被分析了30个情节被重建为叙述和给定的主题，然后根据他们的特征归类为以下9个主要主题：对疼痛/痛苦的判断和应对；关于镇静的冲突；为保护病人的尊严而提供的可控性支持；响应病人意愿的护理；通过团队合作进行的姑息护理；照顾病人的精神痛苦；死亡观察；家庭护理人员面临的挑战；以及护士需要理解和回应家庭护理病人及其家人的意愿。将30集按主题进行分类和组织，并汇编成案例集，在此基础上从四个角度探讨了支持方法，并获得了实际应用的建议。这四个观点是：(1)护士过去的实践经验与他们对护理的态度之间的关系；(2)护士如何理解病人及其家人；(3)考虑到接下来会发生什么以及这些判断是如何进行的；(4)在团队医疗实践中需要和获得的临床智慧。

The purpose of this study was to develop a model for care methodology by analyzing the experience of nurses, specifically the clinical wisdom acquired during the provision of palliative care, and using it to improve the overall process. Taking our cue from Benner’s methods of studying clinical wisdom (1999/2005), we interviewed 20 nurses with three or more years of experience of providing palliative care. The characteristics of the nurses’ judgments and actions were analyzed in relation to 30 episodes that were reconstructed as narratives and given themes, then categorized according to their characteristics into the following nine major themes: judgment on pain/suffering and coping with it; conflict regarding sedation; continence support to protect the patient’s dignity; care that responds to the patient’s wishes; palliative care carried out using teamwork; care for the patient’s mental suffering; deathwatch; challenges faced by family carers; and the need for nurses to understand and respond to the wishes of home-cared patients and their families. The 30 episodes were categorized and organized according to their major themes, then compiled into a collection of cases, based on which we discussed support methodology from four viewpoints and obtained suggestions for practical application. The four viewpoints were (1) the relationship between nurses’ past practical experience and their attitudes to nursing, (2) how nurses understood patients and their families, (3) characteristics of practical judgments that are made considering what will happen next and how these judgments are acted on, and (4) the clinical wisdom both needed and acquired during the practice of team medicine.