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，特别是在提供姑息治疗过程中获得的临床智慧，并利用它来改善整个过程中的护理方法模型。从本纳的研究临床智慧的方法（1999/2005）的线索，我们采访了20名护士提供姑息治疗的经验三年或以上。分析30个事件中护士判断和行动的特征，并将其重构为叙述和给定主题，然后根据其特征将其分为以下9个主题：对疼痛/痛苦的判断和应对;关于镇静的冲突;保护患者尊严的支持;响应患者意愿的护理;通过团队合作开展的姑息治疗;照顾病人的精神痛苦;临终关怀;家庭照顾者面临的挑战;以及护士需要了解和回应家庭护理病人及其家人的愿望。本研究将30集个案按主题分类整理，并整理成个案集，从四个角度探讨支援方法，并提出实际应用的建议。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）护士如何理解病人和他们的家人，（3）实际判断的特点，考虑到接下来会发生什么，这些判断是如何采取行动，和（4）临床智慧都需要和获得在实践中的团队医疗。

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.