背景:针对医院死亡率高的担忧,患者和看护人的投诉,应英国政府的要求,斯塔福德郡中部NHS基金会信托基金进行了公开调查。这项调查发现,所提供的基本护理质量存在严重缺陷,因此,建议患者应该有更多的定期就诊,在可预见的时间由护理人员组织。有意四舍五入,也被称为护理病房查房,被广泛采用以满足这一需求。
目的:为了测试,完善或反驳八种程序理论,以理解什么是有效的,为谁,在什么情况下。
方法:英格兰三个NHS信托中的六个病房(老年人和急性病房)。
方法:董事会级别和高级护理经理(N=17),护理病房工作人员(N=33),专职卫生和医疗专业人员(N=26),患者(N=34)和亲属(N=28)参加了一个个体,用现实主义的方法进行深度访谈。此外,病房护士(N=39)在进行有意查房(共240查房)时被遮蔽,并观察到患者的直接护理(共188小时的患者护理).
方法:混合方法设计包括:阶段(1)理论开发-进行了现实主义综合,以确定经过测试的任何程序理论,精炼和/或反驳,使用来自阶段2和3的数据;阶段(2)对所有英国NHS急性信托的调查;阶段(3)涉及现实主义者访谈的六个病房案例研究,阴影和非参与者观察,分析病房结果和成本数据;以及阶段(4)综合阶段1、2和3的结果。
结果:现实主义综合确定了八种有意四舍五入的程序理论:“一致性和全面性”,\'问责制\',“护士的能见度”,\'预期\',\'分配的照顾时间\',\'护患关系\',“多学科团队合作和沟通”和“患者授权”。主要发现表明,在最初的8个故意四舍五入的方案理论中,只有两个部分解释了干预是如何工作的(“一致性和全面性”和“问责制”)。在剩下的六种计划理论中,2人的证据尚无定论(\'护士的能见度\'和\'预期\'),4人没有证据(\'分配护理时间\';\'护患关系\';\'多学科团队合作和沟通\'和\'患者授权\')。
结论:这是第一个对有意舍入的理论指导评估,证明了在英国医疗保健环境中故意舍入的有效性非常弱。此外,在这项研究中收集的证据挑战并反驳了一些关于有意舍入如何工作的基本假设。这项研究表明,背景在确定干预措施的有效性方面起着至关重要的作用,以及在将为一个国家的卫生系统开发的干预措施实施到另一个国家时需要如何谨慎。
BACKGROUND: In response to concerns about high hospital mortality rates, patient and carer complaints, a Mid Staffordshire NHS Foundation Trust public inquiry was conducted at the request of the UK government. This inquiry found serious failures in the quality of basic care provided and as a consequence, recommended that patients should have more regular visits, organised at predictable times from nursing staff. Intentional rounding, also known as nursing ward rounds, was widely adopted to meet this need.
OBJECTIVE: To test, refine or refute eight programme theories to understand what works, for whom, and in what circumstances.
METHODS: Six wards (older people and acute wards) in three NHS trusts in England.
METHODS: Board level and senior nursing managers (N = 17), nursing ward staff (N = 33), allied health and medical professionals (N = 26), patients (N = 34) and relatives (N = 28) participated in an individual, in-depth interview using the realist method. In addition, ward-based nurses (N = 39) were shadowed whilst they conduced intentional rounds (240 rounds in total) and the direct care of patients (188 h of patient care in total) was observed.
METHODS: The mixed methods design included: Phase (1) Theory development - A realist synthesis was undertaken to identify any programme theories which were tested, refined and/or refuted, using data from phases 2 and 3; Phase (2) A survey of all English NHS acute Trusts; Phase (3) Six case studies of wards involving realist interviews, shadowing and non-participant observations, analysis of ward outcome and cost data; and Phase (4) Synthesis of findings from phases 1, 2 and 3.
RESULTS: The realist synthesis identified eight programme theories of intentional rounding: \'Consistency and comprehensiveness\', \'Accountability\', \'Visibility of nurses\', \'Anticipation\', \'Allocated time to care\', \'Nurse-patient relationships\', \'Multi-disciplinary teamwork and communication\' and \'Patient empowerment\'. Key findings showed that of the original eight programme theories of intentional rounding, only two partially explained how the intervention worked (\'Consistency and comprehensiveness\' and \'Accountability\'). Of the remaining six programme theories, the evidence for two was inconclusive (\'Visibility of nurses\' and \'Anticipation\') and there was no evidence for four (\'Allocated time to care\'; \'Nurse-patient relationships\'; \'Multi-disciplinary teamwork and communication\'; and \'Patient empowerment\').
CONCLUSIONS: This first theory-informed evaluation of intentional rounding, demonstrates that the effectiveness of intentional rounding in the English healthcare context is very weak. Furthermore, the evidence collected in this study has challenged and refuted some of the underlying assumptions about how intentional rounding works. This study has demonstrated the crucial role context plays in determining the effectiveness of an intervention and how caution is needed when implementing interventions developed for the health system of one country into another.