2型糖尿病患者的延续护理体验和需求

Transitional Care Experience and Demands of Patients with Type 2 Diabetes: A Qualitative Research

目的描述2型糖尿病患者对目前延续护理的态度、体验及需求,了解延续护理实施现状及患者护理需求,为建立符合患者需求的延续护理模式提供信息支持。方法采用质性研究的现象学研究方法,对16例2型糖尿病患者进行半结构访谈。结果目前以电话随访为主的延续护理服务形式较单一,专业支持欠缺、出院后管理衔接不足,自我应对不足,不能满足患者护理需求。患者对延续护理服务内容、形式的需求呈现多元化和个性化,患者希望采用"医院-社区-家庭"联动的管理方式、延续护理能尽早实施,缩短随访周期、扩展延续护理服务内涵、希望进行个性化的信息延续方式、接受专科护士的延续护理服务,并参与临床决策、提高健康风险识别能力。结论要形成医院-社区-家庭联动的管理模式,构建科学严谨的延续护理方案,着力打造以专科护士为主导的多学科延续护理管理团队,提高患者延续护理认知度及参与度,积极帮助患者树立正确的健康信念,构建科学的健康行为。

Objective To investigate the performance and patients＇ demand based on the altitude, experience and demand of the patients with type 2 diabetes towards the present transitional care. Methods Semi-structured interview was made to 18 patients with type 2 diabetes and the collected information was studied with phenomenological analysis. Results The information analysis indicated the degree of cognition and participation of transitional care was low in patients and the service capacity of transitional care in hospital or community was not full enough; patients had strong demand for a ＂hospital- community-family＂ managing model of transitional care, an early performance of full transitional care, a shortened followup circle, more service contents in transitional care, personalized information delivery, transitional care by specialized nurses and participation in clinical treatment decision, a higher capacity of health risk identification.. Conclusions It is necessary to construct a hospital-community-family interaction management model, put forward a scientific and rigorous transitional care program, set up a multidisciplinary transitional care managing team dominated by specialized nurses, and more, to raise the awareness and participation of patients in transitional care.