Development of a nurse-led shared care model for palliative care in advanced cancer patients in tertiary general hospitals
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摘要:
目的 构建科学可行的用于三级综合医院护士主导晚期肿瘤患者安宁疗护共照服务模式。 方法 通过专家小组会议和文献检索，根据国家发布的安宁疗护指南服务内容从结构、过程、结果构建三级综合医院安宁疗护共照服务模式指标体系，采用德尔菲法，对15名安宁疗护专家进行2轮函询调查，并按照专家意见进行修改。 结果 15名专家参与了全部函询过程，问卷回收率均为100%。通过两轮德尔菲法，从最初的104个指标列表中最终确定了3个一级指标、9个二级指标、26个三级指标和35个四级指标体系。涵盖9个主题(组织架构、团队成员、单元布置与布局、岗位职责和要求、实施时间、工作模式、实施方案、核心服务内容、服务质量评价)，第一轮和第二轮咨询的专家判断系数分别为0.807和0.840；专家熟悉系数分别为0.780和0.793；专家权威系数(Cr)分别为0.793和0.817。各级指标条目的重要程度肯德尔和谐系数为0.254~0.636，可操作性肯德尔和谐系数为0.305~0.624，指标各条目重要性评分和可操作性评分均>4.0，均值标准差均 < 1.0、指标重要性和可操作性变异系数均 < 0.15，P < 0.01。 结论 构建的晚期肿瘤患者安宁疗护共照体系服务模式内容全面，护士主导可行，具有较高的科学性，能进一步推动三级综合医院晚期肿瘤患者安宁疗护工作。 Abstract:Objective To establish a scientifically feasible nurse-led shared care model for palliative care in advanced cancer patients within tertiary general hospitals. Methods In accordance with national palliative care guidelines, an initial indicator system for the shared care model was devised across three dimensions (structure, process and outcome) through expert panel discussions and a review of the extant literature. A two-round Delphi survey was conducted among 15 palliative care specialists, with revisions made according to expert feedback. Results All 15 experts involved in the consultation completed both rounds of consultation (response rate: 100%). The Delphi was utilized to refine the initial list of 104 indicators was refined into a final framework comprising 3 first-level, 9 second-level, 26 third-level, and 35 fourth-level indicators, which are distributed across 9 themes (organizational structure, team composition, unit configuration, role specifications, implementation timeline, workflow design, operational protocols, core services and quality evaluation). The expert judgment coefficients were 0.807 (Round 1) and 0.840 (Round 2); the familiarity coefficients were 0.780 and 0.793; and the authority coefficients (Cr) were 0.793 and 0.817, respectively. The Kendall's W for indicator importance ranged from 0.254 to 0.636, while the operational feasibility ranged from 0.305 to 0.624. The results indicated that all indicators achieved a score greater than 4.0 (mean) for importance and feasibility, with standard deviations less than 1.0 and coefficients of variation less than 0.15 (P < 0.01). Conclusion The developed nurse-led shared care model for advanced cancer patients is comprehensive, feasible, and scientifically rigorous, providing a practical framework to enhance palliative care delivery in tertiary general hospitals. -
Key words:
- Neoplasms /
- Hospice care /
- Shared care model /
- Nurse-led
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表 1 函询专家基本信息
Table 1. Demographic and professional characteristics of the expert panel
项目 类别 人数(%) 性别 男性 2(13.33) 女性 13(86.67) 年龄(岁) 30~39 2(13.33) 40~50 8(53.33) >50 5(33.33) 职称 主任护师 2(13.33) 副主任护师 8(53.33) 主管护师 2(13.33) 主任医师 1(6.67) 副主任医师 1(6.67) 担任导师情况 博士生导师 0 硕士生导师 8(53.33) 无 7(46.67) 工作时间(年) 5~9 2(13.33) 10~20 6(40.00) >20 7(46.67) 学历 博士 1(6.67) 硕士 7(46.67) 本科 7(46.67) 是否为肿瘤专科护士 是 3(20.00) 否 12(80.00) 是否安宁疗护专科护士 是 4(26.67) 否 11(73.33) 
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表 2 专家问卷回收情况和权威程度
Table 2. Response rate and authority evaluation of the expert consultation
轮次 发放问卷数 问卷回收数 有效率(%) 判断系数 熟悉程度 权威系数 1 15 15 100.00 0.807 0.780 0.793 2 15 15 100.00 0.840 0.793 0.817
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表 3 专家意见的协调系数
Table 3. Coordination coefficients of expert opinions
指标 条目数(个) 重要程度 可操作性 肯德尔和谐系数 χ2值 P值 肯德尔和谐系数 χ2值 P值 一级 3 0.636 19.077 < 0.001 0.624 18.727 < 0.001 二级 9 0.389 46.627 < 0.001 0.381 45.765 < 0.001 三级 26 0.254 95.287 < 0.001 0.305 114.404 < 0.001 四级 35 0.352 179.316 < 0.001 0.333 169.949 < 0.001
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表 4 安宁疗护共照体系一、二级指标重要性和可操作性评分(第2轮)
Table 4. Importance and feasibility scores of primary and secondary indicators in the palliative shared care system (Round 2)
一、二级指标名称 重要性 可操作性 评分(x±s，分) 变异系数 评分(x±s，分) 变异系数 Ⅰ结构指标 4.93±0.26 0.05 5.00±0.00 0.00 Ⅰ-1组织构架 5.00±0.00 0.00 4.40±0.51 0.12 Ⅰ-2团队成员 4.93±0.26 0.05 4.33±0.49 0.11 Ⅰ-3单元布置与布局 4.40±0.51 0.12 4.47±0.52 0.12 Ⅰ-4岗位职责和要求 4.27±0.46 0.11 4.20±0.41 0.10 Ⅱ过程指标 4.13±0.35 0.09 4.87±0.35 0.07 Ⅱ-1实施时间 4.40±0.51 0.12 5.00±0.00 0.00 Ⅱ-2工作模式 4.40±0.51 0.12 4.27±0.46 0.11 Ⅱ-3实施方案 5.00±0.00 0.00 5.00±0.00 0.00 Ⅱ-4核心服务内容 4.33±0.49 0.11 4.80±0.41 0.09 Ⅲ结果指标 4.80±0.41 0.09 4.27±0.46 0.11 Ⅲ-1服务质量评价 4.80±0.41 0.09 4.40±0.51 0.12
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表 5 安宁疗护共照体系三、四级指标重要性和可操作性评分(第2轮)
Table 5. Importance and feasibility scores of tertiary and quaternary indicators in the palliative shared care system (Round 2)
三、四级指标名称 重要性 可操作性 评分(x±s，分) 变异系数 评分(x±s，分) 变异系数 Ⅰ-1-1职能部门 4.20±0.41 0.10 4.33±0.49 0.11 Ⅰ-1-2临床科室 4.47±0.52 0.12 4.40±0.51 0.12 Ⅰ-1-3专科小组 4.67±0.49 0.10 5.00±0.00 0.00 Ⅰ-2-1普通病房医护 4.27±0.46 0.11 4.87±0.35 0.07 Ⅰ-2-2安宁疗护医护 4.60±0.51 0.11 4.67±0.49 0.10 Ⅰ-2-3心理咨询师 4.80±0.41 0.09 4.07±0.26 0.06 Ⅰ-2-4营养师 4.80±0.41 0.09 4.93±0.26 0.05 Ⅰ-2-5志愿者 4.67±0.49 0.10 4.13±0.35 0.09 Ⅰ-3-1病床布局 4.47±0.52 0.12 4.80±0.41 0.09 Ⅰ-3-2病房设置 4.93±0.26 0.05 4.40±0.51 0.12 Ⅰ-3-2-1谈心室 4.33±0.49 0.11 5.00±0.00 0.00 Ⅰ-3-2-2沐浴室 4.67±0.49 0.10 5.00±0.00 0.00 Ⅱ-1-1开始时间 4.20±0.41 0.10 4.40±0.51 0.12 Ⅱ-1-2结束时间 4.73±0.46 0.10 4.33±0.49 0.11 Ⅱ-2-1一个工作组 4.27±0.46 0.11 4.93±0.26 0.05 Ⅱ-2-2N张共照病床 4.53±0.52 0.11 4.40±0.51 0.12 Ⅱ-3-1会诊 4.33±0.49 0.11 5.00±0.00 0.00 Ⅱ-3-2转介 4.73±0.46 0.10 4.40±0.51 0.12 Ⅱ-3-2-1安宁疗护共照病床 4.40±0.51 0.12 5.00±0.00 0.00 Ⅱ-3-2-2下级社区医院 4.33±0.49 0.11 4.47±0.52 0.12 Ⅱ-3-2-3居家安宁 4.40±0.51 0.12 4.47±0.52 0.12 Ⅱ-3-3身体状况评估 4.73±0.46 0.10 5.00±0.00 0.00 Ⅱ-3-3-1预期生存期评估 4.27±0.46 0.11 4.93±0.26 0.05 Ⅱ-3-3-2躯体评估 4.27±0.46 0.11 4.93±0.26 0.05 Ⅱ-3-3-3心理评估 4.47±0.52 0.12 4.40±0.51 0.12 Ⅱ-3-3-4社会关系评估 4.40±0.51 0.12 4.47±0.52 0.12 Ⅱ-3-3-5精神评估 4.60±0.51 0.11 4.53±0.52 0.11 Ⅱ-3-4多学科讨论 4.60±0.51 0.11 4.87±0.35 0.07 Ⅱ-4-1症状管理 4.73±0.46 0.10 4.40±0.51 0.12 Ⅱ-4-1-1疼痛 4.87±0.35 0.07 5.00±0.00 0.00 Ⅱ-4-1-2呼吸困难 4.93±0.26 0.05 4.40±0.51 0.12 Ⅱ-4-1-3咳嗽咳痰 4.73±0.46 0.10 4.87±0.35 0.07 Ⅱ-4-1-4恶心呕吐 4.87±0.35 0.07 4.33±0.49 0.11 Ⅱ-4-1-5发热 4.80±0.41 0.09 4.67±0.49 0.10 Ⅱ-4-1-6水肿 4.07±0.26 0.06 4.40±0.51 0.12 Ⅱ-4-1-7厌食和恶病质 4.40±0.51 0.12 4.27±0.46 0.11 Ⅱ-4-1-8睡眠障碍 4.93±0.26 0.05 4.40±0.51 0.12 Ⅱ-4-2舒适照护 4.80±0.41 0.09 4.93±0.26 0.05 Ⅱ-4-2-1口腔护理 4.27±0.46 0.11 4.40±0.51 0.12 Ⅱ-4-2-2胃肠减压护理 4.67±0.49 0.10 4.40±0.51 0.12 Ⅱ-4-2-3留置尿管护理 4.20±0.41 0.10 4.47±0.52 0.12 Ⅱ-4-2-4便秘护理 4.87±0.35 0.07 5.00±0.00 0.00 Ⅱ-4-2-5造口护理 4.60±0.51 0.11 4.40±0.51 0.12 Ⅱ-4-2-6卧位护理 4.93±0.26 0.05 5.00±0.00 0.00 Ⅱ-4-2-7静脉通路护理 4.33±0.49 0.11 4.33±0.49 0.11 Ⅱ-4-2-8芳香疗法 4.53±0.52 0.11 4.73±0.46 0.10 Ⅱ-4-3心理社会支持 4.93±0.26 0.05 4.33±0.49 0.11 Ⅱ-4-3-1告知坏消息 4.93±0.26 0.05 4.93±0.26 0.05 Ⅱ-4-3-2心理危机干预 4.93±0.26 0.05 4.47±0.52 0.12 Ⅱ-4-3-3照顾者支持 4.87±0.35 0.07 4.53±0.52 0.11 Ⅱ-4-4精神照护 4.20±0.41 0.10 4.67±0.49 0.10 Ⅱ-4-4-1人生回顾 4.27±0.46 0.11 4.67±0.49 0.10 Ⅱ-4-4-2尊严疗法 4.13±0.35 0.09 5.00±0.00 0.00 Ⅱ-4-4-3家庭会议 4.27±0.46 0.11 4.93±0.26 0.05 Ⅱ-4-4-4志愿者服务 4.20±0.41 0.10 4.40±0.51 0.12 Ⅱ-4-5哀伤辅导 4.27±0.46 0.11 4.60±0.51 0.11 Ⅱ-4-5-1死亡教育 4.60±0.51 0.11 5.00±0.00 0.00 Ⅱ-4-5-2延续服务 4.13±0.35 0.09 4.87±0.35 0.07 Ⅲ-1-1服务内容评价 4.80±0.41 0.09 5.00±0.00 0.00 Ⅲ-1-2服务效果评价 4.87±0.35 0.07 4.73±0.46 0.10 Ⅲ-1-3改进、反馈 4.27±0.46 0.11 4.80±0.41 0.09
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