Development of Educational Program for nurses-nurses Collaboration to Provide Community-based Palliative Care for Individuals with ALS

本研究的目的是提供建议的方法之间的合作（护士-护士合作）和在职教育的疑难杂症护理需要提供姑息治疗的各种疼痛和痛苦的ALS患者及其家属从诊断到死亡在整个社区。作为这项研究的结果，我们发现，需要特别加强合作以支持以疾病进展为特征的ALS患者的最重要时间是在疾病的早期阶段，疾病的快速进展阶段和疾病的晚期阶段。在家庭成员的教育和照顾方面，加强医院护士和家访护士之间的合作是重要的。作为各类护理人员教育的重要内容，重视对患者及家属的心理状态的护理教育尤为重要。同样显而易见的是，公共卫生护士应该知道如何参与疾病的早期阶段，并了解其呼吸系统并发症，家访护士应该了解家庭终末护理的方法，出院计划护士在加强社区护士和医生之间的合作以及连接医院和社区方面发挥作用。

The purpose of this research was to provide proposals for methods of collaboration among nurses (nurse-nurse collaboration) and for in-service education for intractable-disease nursing needed when providing palliative care for various pains and distresses experienced by ALS patients and their families from diagnosis to death in the whole community. As a result of this research, we found that the most important times at which the collaboration needs to be particularly strengthened for supporting ALS patients, characterized by progressive disease, are at the early stage of the disease, at the time of rapid progression of the disease, and in the terminal stage of the disease. For family members' education and care, strengthening of collaboration between hospital nurses and home-visit nurses is important. As an important content of the education for all types of nurses, education focusing on care of the mental status of the patients and family members is considered important. It has also become apparent that public health nurses should know how to get involved in the early stage of the disease and have knowledge about its respiratory complications, home-visit nurses should be aware of the methods of at-home terminal care, and hospital discharge planning nurses have a role in strengthening the collaboration between community nurses and doctors and to connect hospitals and communities.